Use of flow-diverter devices in low- to middle- income countries for unruptured right communicating segment ICA aneurysm presenting as bitemporal hemianopsia: A Systematic Review and Illustrative Case

Introduction: Vast majority of unruptured intracranial aneurysms (UIA) do not show symptoms, with only around 10% becoming apparent before rupture, typically displaying signs of compression effects secondary to large or rapidly growing aneurysms which leads to urgent treatment.

Methods: We report a case of 59-year-old male with an unruptured right communicating segment ICA aneurysm presenting as bitemporal hemianopsia who was treated with flow-diverter stent and partial coil embolization. We also performed a systematic review of patients with ICA aneurysms presenting with neuro-ophthalmologic symptoms treated with flow diverter stents and discussed the clinical features and outcomes.

Results: A total of 856 patients who had UIA were treated with different flow diverter devices (Derivo, FRED, p64, PED, Surpass and SILK). In study of Griessenauer et al, 10% of patients experienced prompt improvement in visual function, while 2 patients developed new visual impairment, and in the meta-analysis of Kaiser et al, a complete recovery from their initial impairment was observed in 48% of the patients, while nearly 75% displayed improvement in symptoms related to compression. Most common morbidity encountered across studies were related to hemorrhagic and ischemic complications which accounts for 3.7% in one study.

Conclusion : Flow-diverter devices offer an additional advantage by reducing the mass effect of the aneurysm sac, which is beneficial for aneurysms in patients experiencing compression symptoms, as compared to clipping or coiling alone. Early detection and treatment increases the likelihood of symptom improvement, hence prioritization of this intervention over other modalities is crucial, especially in a setting such as here in the Philippines wherein limited facility are capable for these endovascular interventions.