Patient Management After Flow Diversion for Unruptured Intracranial Aneurysms: a Literature Review and DELPHI Consensus
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Stebner A.
Schungel M.S.
Bosshart S.L.
Fujiwara S.
Milot G.
Volders D.
Uchida K.
Hawkes C.
Cimflova P.
Moreu M.
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2025
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BACKGROUND: Unruptured intracranial aneurysms are a common and can have devastating outcomes if ruptured. Flow diversion has expanded treatment options, especially for wide-necked and blister aneurysms. Yet, optimal follow-up retreatment strategies in case of treatment failure remain unclear. A DELPHI consensus was initiated to understand current practice in aneurysm management after flow diverter treatment. METHOD(S): This DELPHI consensus was conducted during the 5 T Think Tank, following a scoping literature review. Experts discussed the results, responded to iterative questionnaires, which started with four open-ended questions, and concluded with ten closed-ended questions. RESULT(S): Of the 40 attendees, 24 participants (60%) identified as experts in flow diversion and participated in the DELPHI process, which involved a literature search and three DELPHI rounds. Consensus was reached on performing the first assessment of the flow diverter during the procedure using cone-beam CT (77.8%), and on timing of the first follow up (at 6 months, 70.8%). For follow-up timing, an annual (57%) or semi-annual (43%) schedule was favored. No preference emerged for the follow-up imaging modality, with slight preferences for MRA (29%), followed by DSA (25%), DSA + MRA (21%), CTA (17%), and DSA + CTA (8%). Aneurysm growth (> 2 mm) was identified as a key criterion for retreatment. It was thought that combining clinical and angiographic metrics should be a key research priority, as it could potentially improve retreatment decision making compared to a purely angiographic outcome. CONCLUSION(S): This DELPHI consensus highlights the complexity of decision-making for unruptured intracranial aneurysms. Despite these challenges, there was consensus among international experts on follow-up timing and decision drivers for retreatment. Copyright © 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.
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Clinical neuroradiology