Endovascular insertion of an intrasaccular wire-mesh blood-flow disruption device for intracranial aneurysms

Evidence-based recommendations on endovascular insertion of an intrasaccular wire-mesh blood-flow disruption device for intracranial aneurysms in adults. This involves inserting a wire-mesh device into the aneurysm to act as a plug when a blood clot forms inside it.

# Recommendations
Current evidence on the safety and efficacy of endovascular insertion of an intrasaccular wire-mesh blood-flow disruption device for intracranial aneurysms is adequate to support the use of this procedure provided that standard arrangements are in place for clinical governance, consent and audit. Find out what standard arrangements mean on the NICE interventional procedures guidance page.
Patient selection should be done by a multidisciplinary team, except for in emergency situations, when this may be replaced by a discussion between an interventional neuroradiologist and neurosurgeon.
The procedure should only be done in specialised centres with expertise in the use of this technology and access to neurosurgical facilities.# The condition, current treatments and procedure

# The condition
An intracranial aneurysm is a bulge in a blood vessel in the brain caused by a weakness in the blood vessel wall, usually where it branches. Most brain aneurysms only cause noticeable symptoms if they rupture. However, large aneurysms may cause local compression symptoms before they rupture, such as headache. Rupture of intracranial aneurysms causes subarachnoid haemorrhage and is associated with a very poor prognosis. About 10% of people die before reaching hospital and a further 50% die within 4 weeks. About 50% of people who survive a subarachnoid haemorrhage have a persistent neurological deficit.
If an intracranial aneurysm is detected before it ruptures, treatment may be recommended to prevent it rupturing in the future. This is typically only done if the risk of a rupture is particularly high.

# Current treatments
Current options for managing intracranial aneurysms include coiling, often with stent placement (stent-assisted coiling), neurosurgical clipping through a craniotomy (with or without bypass procedures), parent vessel occlusion (by open neurosurgery or by endovascular means) and conservative management. Flow diverter embolisation devices, which are placed in the parent blood vessel to divert blood flow away from the aneurysm itself, may be an option for some people with intracranial aneurysms.

# The procedure
Endovascular insertion of an intrasaccular wire-mesh blood-flow disruption device for intracranial aneurysms is used for the embolisation of ruptured and unruptured intracranial aneurysms. It may be particularly suitable for people with wide-necked aneurysms. The procedure is usually done under general anaesthesia. A catheter is inserted into the femoral artery and advanced into the cerebral circulation under Xray guidance. A second, smaller catheter is put inside the first and is inserted into the aneurysm. A basket-like device made of fine wire mesh is then pushed through the second catheter and placed into the aneurysm sac. The mesh device covers the aneurysm neck and obstructs blood flow into the aneurysm sac, creating blood stasis and promoting endothelial growth across the neck of the aneurysm. The appropriate device size is selected according to the aneurysm width and height.
The aim is to prevent the aneurysm from rupturing or to stop further bleeding from an aneurysm that has already ruptured.