Abstract：
OBJECTIVE: The placement of flow-diverting devices has become a common method of treating unruptured intracranial aneurysms of the internal carotid artery. The progressive improvement of aneurysm occlusion after treatment-with low complication and rupture rates-has led to a dilemma regarding the management of aneurysms in which occlusion has not occurred within 6-24 months. The authors aimed to identify clinical consensus regarding management of intracranial aneurysms displaying persistent filling 6-24 months after flow diversion and to ascertain questions that may drive future investigation.
METHODS: An international panel of 67 experts was invited to participate in a multistep Delphi consensus process on the treatment of intracranial aneurysms after failed flow diversion.
RESULTS: Of the 67 experts invited, 23 (34%) participated. Qualitative analysis of an initial survey with open-ended questions resulted in 51 statements regarding management of aneurysms showing persistent filling after flow diversion. The statements were grouped into 8 categories, and in the second round, respondents rated the degree of their agreement with each statement on a 5-point Likert scale. Flow diverters with surface modifiers did not influence administration of dual-antiplatelet therapy according to 83%. Consensus was also reached regarding the definition of treatment failure at specific time points, including at 6 months if there is aneurysm growth or persistent rapid flow through the entirety of the aneurysm (96%), at 12 months if there is aneurysm growth or symptom onset (78%), and at 24 months if there is persistent filling regardless of size and filling characteristics (74%). Although experts agreed that the degree of intimal hyperplasia or in-device stenosis could not be ascertained by noninvasive imaging alone (83%), only 65% chose digital subtraction angiography as the preferred modality. At 6 and 12 months, retreatment is preferred if there is persistent filling with aneurysm growth (96%, 96%), device malposition (48%, 87%), or a history of subarachnoid hemorrhage (65%, 70%), respectively, and at 24 months if there is persistent filling without reduction in aneurysm size (74%). Experts favored treatment with an additional flow diverter (87%) over aneurysm clipping, applying the same principles for follow-up (83%) and treatment failure (91%) as for the first flow diverter.
CONCLUSIONS: The authors present the consensus practices of experts in the management of intracranial aneurysms without occlusion 6-24 months after treatment with a flow-diverting device.
METHODS: An international panel of 67 experts was invited to participate in a multistep Delphi consensus process on the treatment of intracranial aneurysms after failed flow diversion.
RESULTS: Of the 67 experts invited, 23 (34%) participated. Qualitative analysis of an initial survey with open-ended questions resulted in 51 statements regarding management of aneurysms showing persistent filling after flow diversion. The statements were grouped into 8 categories, and in the second round, respondents rated the degree of their agreement with each statement on a 5-point Likert scale. Flow diverters with surface modifiers did not influence administration of dual-antiplatelet therapy according to 83%. Consensus was also reached regarding the definition of treatment failure at specific time points, including at 6 months if there is aneurysm growth or persistent rapid flow through the entirety of the aneurysm (96%), at 12 months if there is aneurysm growth or symptom onset (78%), and at 24 months if there is persistent filling regardless of size and filling characteristics (74%). Although experts agreed that the degree of intimal hyperplasia or in-device stenosis could not be ascertained by noninvasive imaging alone (83%), only 65% chose digital subtraction angiography as the preferred modality. At 6 and 12 months, retreatment is preferred if there is persistent filling with aneurysm growth (96%, 96%), device malposition (48%, 87%), or a history of subarachnoid hemorrhage (65%, 70%), respectively, and at 24 months if there is persistent filling without reduction in aneurysm size (74%). Experts favored treatment with an additional flow diverter (87%) over aneurysm clipping, applying the same principles for follow-up (83%) and treatment failure (91%) as for the first flow diverter.
CONCLUSIONS: The authors present the consensus practices of experts in the management of intracranial aneurysms without occlusion 6-24 months after treatment with a flow-diverting device.
摘要：
目的：放置分流装置已成为治疗颈内动脉未破裂颅内动脉瘤的常用方法。治疗后动脉瘤闭塞的逐步改善-并发症和破裂率低-导致了在6-24个月内未发生闭塞的动脉瘤管理方面的困境。作者旨在确定在分流后6-24个月表现出持续充盈的颅内动脉瘤治疗的临床共识，并确定可能推动未来研究的问题。
方法：一个由67名专家组成的国际小组应邀参加了一项关于分流失败后颅内动脉瘤治疗的多步骤德尔菲共识过程。
结果：在邀请的67位专家中，23人（34%）参加。对带有开放式问题的初始调查进行定性分析，得出了51种有关动脉瘤管理的陈述，表明分流后持续充盈。这些声明分为8类，在第二轮中,受访者以5分的李克特量表评估了他们对每个陈述的同意程度。具有表面改性剂的分流器对双重抗血小板治疗的给药没有影响，占83％。关于在特定时间点治疗失败的定义也达成了共识，包括在6个月时，如果存在动脉瘤生长或通过整个动脉瘤的持续快速流动（96％），在12个月时，如果有动脉瘤生长或症状发作（78%），在24个月时，无论大小和填充特征如何，如果存在持续填充(74%)。尽管专家们一致认为内膜增生或器械内狭窄的程度不能仅通过无创成像来确定（83%），只有65%的人选择数字减影血管造影作为首选方式.在6个月和12个月时，如果存在动脉瘤生长的持续充盈，则首选再治疗(96%，96%），设备错位(48%，87%），或蛛网膜下腔出血史（65%，70%)，分别,在24个月时，如果存在持续充盈而不减小动脉瘤大小（74％）。专家更喜欢用额外的分流器（87％）治疗动脉瘤夹闭术，采用与第一个分流器相同的随访原则（83％）和治疗失败原则（91％）。
结论：作者介绍了专家在使用分流装置治疗6-24个月后处理无闭塞颅内动脉瘤的共识做法。
方法：一个由67名专家组成的国际小组应邀参加了一项关于分流失败后颅内动脉瘤治疗的多步骤德尔菲共识过程。
结果：在邀请的67位专家中，23人（34%）参加。对带有开放式问题的初始调查进行定性分析，得出了51种有关动脉瘤管理的陈述，表明分流后持续充盈。这些声明分为8类，在第二轮中,受访者以5分的李克特量表评估了他们对每个陈述的同意程度。具有表面改性剂的分流器对双重抗血小板治疗的给药没有影响，占83％。关于在特定时间点治疗失败的定义也达成了共识，包括在6个月时，如果存在动脉瘤生长或通过整个动脉瘤的持续快速流动（96％），在12个月时，如果有动脉瘤生长或症状发作（78%），在24个月时，无论大小和填充特征如何，如果存在持续填充(74%)。尽管专家们一致认为内膜增生或器械内狭窄的程度不能仅通过无创成像来确定（83%），只有65%的人选择数字减影血管造影作为首选方式.在6个月和12个月时，如果存在动脉瘤生长的持续充盈，则首选再治疗(96%，96%），设备错位(48%，87%），或蛛网膜下腔出血史（65%，70%)，分别,在24个月时，如果存在持续充盈而不减小动脉瘤大小（74％）。专家更喜欢用额外的分流器（87％）治疗动脉瘤夹闭术，采用与第一个分流器相同的随访原则（83％）和治疗失败原则（91％）。
结论：作者介绍了专家在使用分流装置治疗6-24个月后处理无闭塞颅内动脉瘤的共识做法。
