Case Report: PipelineTM Flex flow diverter for an unruptured MCA Bifurcation Aneurysm and parent artery stenosis with 49 months follow-up

Case Report: PipelineTM Flex flow diverter for an unruptured MCA Bifurcation Aneurysm and parent artery stenosis with 49 months follow-up | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case Report: PipelineTM Flex flow diverter for an unruptured MCA Bifurcation Aneurysm and parent artery stenosis with 49 months follow-up Zhejing Ding, Tao An, Yongkang Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7339773/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background The effective treatment of middle cerebral artery (MCA) bifurcation aneurysms remains challenging and is often prone to complications when treating aneurysms in these sites. FDs treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. At the same time, the FDs demonstrated satisfactory performance in terms of periprocedural complications, favorable clinical outcomes, and complete occlusion on follow-up imaging in the management of intracranial aneurysms accompanied by parent artery stenosis. However, there is little data to support FDs treatment for middle cerebral bifurcation aneurysms combined with parent artery stenosis. Case presentation A 54-year-old male patient came to hospital for treatment due to repeated left limb weakness and had a history of hypertension for more than 10 years. Complete digital subtraction angiography (DSA) confirmed that there was local severe stenosis in the M1 segment of the right middle cerebral artery, and an aneurysm formed at the distal bifurcation. The preoperative diagnosis was TIA and an aneurysm in the middle bifurcation of the right side of the brain. The patient was treated with balloon dilation and injection of a flow-diverter device for the treatment of bifurcation aneurysm and stenosis. Patients should take medication regularly before and after surgery and have regular follow-up. During the 49-month postoperative follow-up, the patient did not experience ischemic events or aneurysm recurrence. Conclusions FDs’ treatment is feasible in patients with bifurcation aneurysms of the middle cerebral artery with stenosis of the parent artery, and for bifurcation aneurysms, the safety and efficacy of FDs’ treatment is comparable to other available endovascular options. At the same time, for parent artery stenosis, it has shown satisfactory performance in terms of perioperative complications, good clinical outcomes, and complete occlusion on subsequent imaging. Middle cerebral artery stenosis Middle cerebral bifurcation aneurysm Flow diverter Transient ischemic attack(TIA) Digital subtraction angiography (DSA) Figures Figure 1 Figure 2 Figure 3 Background The effective treatment of middle cerebral artery (MCA) bifurcation aneurysms remains challenging and is often prone to complications when treating aneurysms in these sites [ 1 ]. FDs treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms [ 2 ]. At the same time, the FDs demonstrated satisfactory performance in terms of periprocedural complications, favorable clinical outcomes, and complete occlusion on follow-up imaging in the management of intracranial aneurysms accompanied by parent artery stenosis [ 3 ]. However, there is little data to support FDs treatment for middle cerebral bifurcation aneurysms combined with parent artery stenosis. Case presentation A 54-year-old man presented to our hospital with recurrent episodes of left limb weakness. The patient complained of weakness in the left limb at each symptom attack, mainly difficulty in walking and unsteadiness in holding objects, and the symptoms resolved spontaneously about 30 minutes after rest. Neurological examination showed no obvious positive signs on admission. The head MR examination showed no obvious new acute ischemic cerebral infarction (Fig. 1 A, 1 B). After Digital subtraction angiography (DSA) was completed, it was confirmed that there was localized severe stenosis of the R-MCA M1 segment with aneurysm formation at the distal bifurcation(Fig. 1 C, 1 D). After receiving Aspirin 100 mg qd and Ticagrelor 60 mg bid for 5 days, the patient underwent RX-balloon dilation and Pipeline™ Flex (PED; ev3/Covidien, Irvine, CA, USA) Flow-Diverter (FD) implantation of the right middle cerebral artery under general anesthesia with endotracheal intubation. The patient was discharged 3 days after surgery with no significant neurological deficits at the time of discharge. During the follow-up of 6 months and 49 months after surgery, there were no in-stent stenosis during the follow-up with DSA and cerebral ischemic events (Fig. 2 A, 2 B, 3 A and 3 B). Discussion and conclusions The effectiveness of FDs in the treatment of intracranial unruptured aneurysms, especially in certain anatomical locations, such as the internal carotid ophthalmic segment. However, the results of FDs use in small-bore distal vessels remain controversial, especially in the distal middle cerebral artery [ 4 , 5 ]. In recent years, a large number of studies have shown that the use of FDs for MCA aneurysms in the bifurcation of the middle cerebral artery is feasible and has shown good imaging results at follow-up of long-term DSA examinations, while the complication rate is within acceptable limits [ 2 , 6 , 13 , 14 , 15 ]. When FDs were used to treat bifurcation aneurysms, it means covering the branching vessels of the MCA bifurcation. Previous studies have shown that the branching pattern of the MCA backbone is variable, with bifurcation being the most common: 6% have no main branch, 64% have a bifurcation, 29% have two bifurcations, and 1% have four bifurcations. The location of the fork depends on the length of the M1 segment. Only 15% of cases have the same diameter of the main part, and in 50% of cases the lower trunk is dominant [ 7 ]. Saleme, S. et al. showed that the use of FDs for bifurcation aneurysms resulted in occlusion of the covered branches with safe outcomes [ 8 ]. The study of Korkmazer, B. et al. revealed perfusion changes in the area covered by branching blood vessels through MRP examination, which are usually not accompanied by clinical symptoms [ 9 ].The above results show that the treatment of bifurcation aneurysms with FDs are feasible. Prior to this, there was a lack of sufficient evidence-based medical evidence for FDs as a treatment modality in patients with intracranial unruptured aneurysms with stenosis of the carrying artery, but recent studies have shown that FDs provide satisfactory performance in terms of perioperative complications and has achieved good clinical and radiological results in the treatment of intracranial aneurysms with stenosis of the carrying artery [ 10 ]. In particular, the ANSWER technology (ANeurySm With stenosis treatment using fastunnEl deliveRing balloon dilatation catheter, Fastunnel® delivery balloon dilatation catheter for the treatment of aneurysms with stenosis) recently proposed by the team of G.S. professors of the First Affiliated Hospital of Zhengzhou University can be very good in treating aneurysms and stenotic, namely pre-dilation, balloon temporary assistance, balloon protection, and stent placement. Simultaneous treatment of stenosis dilation and aneurysm embolization, avoiding the risk factors of local dissection after pre-dilatation and re-embolization of microcatheters, simplified and safe operation, provides a better choice for the simultaneous treatment of aneurysms and stenosis. This clinical case used the Pipeline™ Flex (PED; ev3/Covidien, Irvine, CA, USA) Flow-Diverter to treat the bifurcation aneurysm of the right middle cerebral aneurysm with stenosis of the parent artery. The postoperative follow-up was up to 49 months, and the results showed the feasibility and safety of the Pipeline™ Flex Flow-Diverter in the treatment of bifurcation aneurysms of the middle cerebral artery [ 2 ]. At the same time, due to the weaving structure of cobalt-chromium alloy, it has sufficient radial support to maintain the lumen shape of the narrowed section of the intracranial artery [ 17 , 18 ]. In the perioperative period, aspirin 100mg qd and ticagrelor 60mg bid were routinely used, and FD implantation was performed after oral administration for 5 days, so as to minimize the risk of acute stent thrombosis after stent implantation [ 11 , 12 ]. In summary, it is safe and feasible to use the Pipeline™ Flex Flow-Diverter to treat aneurysms of the middle cerebral artery bifurcation with parent artery stenosis. Declarations Acknowledgements None. Author contributions ZJ.D. wrote the manuscript and examined the patient. T.A. analyzed the neuroimaging data. ZJ.D. and YK.L. prepared the manuscript and performed the operation on the patient. All the authors read and approved the final version of the manuscript. Funding None. Data availability Not applicable. Ethics approval and consent to participate Not applicable. Consent for publication A signed informed consent was obtained from the patient to publish this case report and the accompanying neuroimages. Competing interests The authors declare no competing interests. References Alfano JM, Kolega J, Natarajan SK, Xiang J, Paluch RA, Levy EI, Meng H. Intracranial aneurysms occur more frequently at bifurcation sites that typically experience higher hemodynamic stresses. Neurosurgery. 2013;73(3):497–505. Salem MM, Khorasanizadeh M, Lay SV, Renieri L, Kuhn AL, Sweid A, Thomas AJ. Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: multicenter cohort. J neurointerventional Surg. 2022;14(11):1084–9. Quan T, Gai Y, Feng X, Saleme S, Liu B, Zhang X, Guan S. Outcomes of flow diversion in intracranial aneurysms accompanied by parent artery stenosis. Journal of NeuroInterventional Surgery; 2025. Gory B, Berge J, Bonafé A, et al. Flow Diverters for Intracranial Aneurysms: The DIVERSION National Prospective Cohort Study. Stroke. 2019;50:3471–80. Di Maria F, Pistocchi S, Clarençon F, et al. Flow Diversion versus Standard Endovascular Techniques for the Treatment of Unruptured Carotid-Ophthalmic Aneurysms. AJNR Am J Neuroradiol. 2015;36:2325–30. Bhogal P, AlMatter M, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. Flow diversion for the treatment of MCA bifurcation aneurysms—a single centre experience. Front Neurol. 2017;8:20. Türe U, Yaşargil MG, Al-Mefty O, Yaşargil DC. Arteries of the insula. J Neurosurg. 2000;92:676–87. 10.3171/jns.2000.92.4.0676 . Saleme S, Iosif C, Ponomarjova S, Mendes G, Camilleri Y, Caire F, Mounayer C. Flow-diverting stents for intracranial bifurcation aneurysm treatment. Neurosurgery. 2014;75(6):623–31. Korkmazer B, Karaman AK, Ustundag A, Arslan S, Kızılkılıç O, Koçer N, Islak C. Magnetic resonance perfusion imaging findings following flow diversion in patients with complex middle cerebral artery bifurcation aneurysms: a single-center analysis regarding the jailed cortical branches. J NeuroInterventional Surg. 2024;16(1):8–14. Quan T, Gai Y, Feng X, Saleme S, Liu B, Zhang X, Guan S. Outcomes of flow diversion in intracranial aneurysms accompanied by parent artery stenosis. Journal of NeuroInterventional Surgery; 2025. Iosif C, Mounayer C, Yavuz K, Saleme S, Geyik S, Cekirge HS, Saatci I. Middle cerebral artery bifurcation aneurysms treated by extrasaccular flow diverters: midterm angiographic evolution and clinical outcome. Am J Neuroradiol. 2017;38(2):310–6. Shapiro M, Shapiro A, Raz E, Becske T, Riina H, Nelson PK. Toward better understanding of flow diversion in bifurcation aneurysms. Am J Neuroradiol. 2018;39(12):2278–83. Chen SQ, Li L, Gao BL, Wu QW, Shao QJ, Wang ZL, Li TX. Safety and effect of pipeline flex embolization device for complex unruptured intracranial aneurysms. Sci Rep. 2023;13(1):4570. Makhambetov Y, Maidan A, Nurimanov C, Kaliyev A, Kunakbayev B, Nurakay N, Makhambetov N. Safety and efficacy of flow diverter stents in the treatment of bifurcation cerebral aneurysms: single-center experience. Diagn Interventional Radiol. 2025;31(4):366. Hellstern V, Brenner N, Cimpoca A, Albina Palmarola P, Henkes E, Wendl C, Henkes H. Flow diversion for unruptured MCA bifurcation aneurysms: comparison of p64 classic, p64 MW HPC, and p48 MW HPC flow diverter stents. Front Neurol. 2024;15:1415861. Milewski K, Zurakowski A, Pajak J, Pajak-Zielinska E, Liszka L, Buszman PP, Buszman PE. Comparison of thin-strut cobalt-chromium stents and stainless steel stents in a porcine model of neointimal hyperplasia. Med Sci monitor: Int Med J experimental Clin Res. 2010;16(1):BR40–4. Jun YJ, Hwang DK, Lee HS, Kim BM, Park KD. Flow diverter performance comparison of different wire materials for effective intracranial aneurysm treatment. Bioengineering. 2024;11(1):76. Oliver AA, Senol YC, Bilgin C, Schaffer JE, Kadirvel R, Kallmes DF, Wainwright JM. Intraluminal flow diverter design primer for neurointerventionalists. Am J Neuroradiol. 2024;45(4):365–70. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers invited by journal 11 Sep, 2025 Editor invited by journal 12 Aug, 2025 Editor assigned by journal 10 Aug, 2025 Submission checks completed at journal 10 Aug, 2025 First submitted to journal 10 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7339773","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":515836531,"identity":"796666b4-bd72-4d53-8284-7131401e9eaa","order_by":0,"name":"Zhejing Ding","email":"","orcid":"","institution":"Zhuhai People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhejing","middleName":"","lastName":"Ding","suffix":""},{"id":515836532,"identity":"b422c57a-80d0-4b15-b821-62c540f0669d","order_by":1,"name":"Tao An","email":"","orcid":"","institution":"Zhuhai People's 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09:29:36","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51893,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7339773/v1/288284141970e4df77084bf7.html"},{"id":91835133,"identity":"e56f9e58-d320-4605-b9d8-38bcba8f758d","added_by":"auto","created_at":"2025-09-22 09:29:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":110938,"visible":true,"origin":"","legend":"\u003cp\u003eThe imaging examinations before operation.\u003c/p\u003e\n\u003cp\u003e(1A, 1B) MR and MRA showed no new cerebral infarction, severe stenosis of the R-MCA, and aneurysm of the bifurcation of the R-MCA.\u003c/p\u003e\n\u003cp\u003e(1C, 1D) DSA: R-MCA.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7339773/v1/19880e9d16661ed6ba4fe4e5.png"},{"id":91835136,"identity":"f5a77787-d5ea-4c67-866a-5ae83c916b03","added_by":"auto","created_at":"2025-09-22 09:29:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":118814,"visible":true,"origin":"","legend":"\u003cp\u003eThe imaging of 6 months follow-up.\u003c/p\u003e\n\u003cp\u003e(2A, 2B) DSA: R-MCA.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7339773/v1/3becef983537930d1df9060e.png"},{"id":91835135,"identity":"b19be013-9583-4254-8e11-f4500da4818a","added_by":"auto","created_at":"2025-09-22 09:29:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":115120,"visible":true,"origin":"","legend":"\u003cp\u003eThe imaging of 49 months follow-up.\u003c/p\u003e\n\u003cp\u003e(3A, 3B) DSA: R-MCA.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7339773/v1/58dec9af4bfd6dd1ebd18265.png"},{"id":91836313,"identity":"8eca079f-7c2c-4cc5-a590-3fffe8a100af","added_by":"auto","created_at":"2025-09-22 09:37:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":736593,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7339773/v1/f2dfa978-dc5e-4f65-83bf-f2fb88d0ff83.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case Report: PipelineTM Flex flow diverter for an unruptured MCA Bifurcation Aneurysm and parent artery stenosis with 49 months follow-up","fulltext":[{"header":"Background","content":"\u003cp\u003eThe effective treatment of middle cerebral artery (MCA) bifurcation aneurysms remains challenging and is often prone to complications when treating aneurysms in these sites [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. FDs treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. At the same time, the FDs demonstrated satisfactory performance in terms of periprocedural complications, favorable clinical outcomes, and complete occlusion on follow-up imaging in the management of intracranial aneurysms accompanied by parent artery stenosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, there is little data to support FDs treatment for middle cerebral bifurcation aneurysms combined with parent artery stenosis.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 54-year-old man presented to our hospital with recurrent episodes of left limb weakness. The patient complained of weakness in the left limb at each symptom attack, mainly difficulty in walking and unsteadiness in holding objects, and the symptoms resolved spontaneously about 30 minutes after rest. Neurological examination showed no obvious positive signs on admission. The head MR examination showed no obvious new acute ischemic cerebral infarction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). After Digital subtraction angiography (DSA) was completed, it was confirmed that there was localized severe stenosis of the R-MCA M1 segment with aneurysm formation at the distal bifurcation(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). After receiving Aspirin 100 mg qd and Ticagrelor 60 mg bid for 5 days, the patient underwent RX-balloon dilation and Pipeline\u0026trade; Flex (PED; ev3/Covidien, Irvine, CA, USA) Flow-Diverter (FD) implantation of the right middle cerebral artery under general anesthesia with endotracheal intubation. The patient was discharged 3 days after surgery with no significant neurological deficits at the time of discharge. During the follow-up of 6 months and 49 months after surgery, there were no in-stent stenosis during the follow-up with DSA and cerebral ischemic events (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB).\u003c/p\u003e"},{"header":"Discussion and conclusions","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cp\u003eThe effectiveness of FDs in the treatment of intracranial unruptured aneurysms, especially in certain anatomical locations, such as the internal carotid ophthalmic segment. However, the results of FDs use in small-bore distal vessels remain controversial, especially in the distal middle cerebral artery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In recent years, a large number of studies have shown that the use of FDs for MCA aneurysms in the bifurcation of the middle cerebral artery is feasible and has shown good imaging results at follow-up of long-term DSA examinations, while the complication rate is within acceptable limits [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhen FDs were used to treat bifurcation aneurysms, it means covering the branching vessels of the MCA bifurcation. Previous studies have shown that the branching pattern of the MCA backbone is variable, with bifurcation being the most common: 6% have no main branch, 64% have a bifurcation, 29% have two bifurcations, and 1% have four bifurcations. The location of the fork depends on the length of the M1 segment. Only 15% of cases have the same diameter of the main part, and in 50% of cases the lower trunk is dominant [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSaleme, S. et al. showed that the use of FDs for bifurcation aneurysms resulted in occlusion of the covered branches with safe outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The study of Korkmazer, B. et al. revealed perfusion changes in the area covered by branching blood vessels through MRP examination, which are usually not accompanied by clinical symptoms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].The above results show that the treatment of bifurcation aneurysms with FDs are feasible.\u003c/p\u003e\u003cp\u003ePrior to this, there was a lack of sufficient evidence-based medical evidence for FDs as a treatment modality in patients with intracranial unruptured aneurysms with stenosis of the carrying artery, but recent studies have shown that FDs provide satisfactory performance in terms of perioperative complications and has achieved good clinical and radiological results in the treatment of intracranial aneurysms with stenosis of the carrying artery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In particular, the ANSWER technology (ANeurySm With stenosis treatment using fastunnEl deliveRing balloon dilatation catheter, Fastunnel\u0026reg; delivery balloon dilatation catheter for the treatment of aneurysms with stenosis) recently proposed by the team of G.S. professors of the First Affiliated Hospital of Zhengzhou University can be very good in treating aneurysms and stenotic, namely pre-dilation, balloon temporary assistance, balloon protection, and stent placement. Simultaneous treatment of stenosis dilation and aneurysm embolization, avoiding the risk factors of local dissection after pre-dilatation and re-embolization of microcatheters, simplified and safe operation, provides a better choice for the simultaneous treatment of aneurysms and stenosis.\u003c/p\u003e\u003cp\u003eThis clinical case used the Pipeline\u0026trade; Flex (PED; ev3/Covidien, Irvine, CA, USA) Flow-Diverter to treat the bifurcation aneurysm of the right middle cerebral aneurysm with stenosis of the parent artery. The postoperative follow-up was up to 49 months, and the results showed the feasibility and safety of the Pipeline\u0026trade; Flex Flow-Diverter in the treatment of bifurcation aneurysms of the middle cerebral artery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. At the same time, due to the weaving structure of cobalt-chromium alloy, it has sufficient radial support to maintain the lumen shape of the narrowed section of the intracranial artery [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the perioperative period, aspirin 100mg qd and ticagrelor 60mg bid were routinely used, and FD implantation was performed after oral administration for 5 days, so as to minimize the risk of acute stent thrombosis after stent implantation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn summary, it is safe and feasible to use the Pipeline\u0026trade; Flex Flow-Diverter to treat aneurysms of the middle cerebral artery bifurcation with parent artery stenosis.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZJ.D. wrote the manuscript and examined the patient. T.A. analyzed the neuroimaging data. ZJ.D. and YK.L. prepared the manuscript and performed the operation on the patient. All the authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA signed informed consent was obtained from the patient to publish this case report and the accompanying neuroimages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlfano JM, Kolega J, Natarajan SK, Xiang J, Paluch RA, Levy EI, Meng H. Intracranial aneurysms occur more frequently at bifurcation sites that typically experience higher hemodynamic stresses. Neurosurgery. 2013;73(3):497\u0026ndash;505.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalem MM, Khorasanizadeh M, Lay SV, Renieri L, Kuhn AL, Sweid A, Thomas AJ. Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: multicenter cohort. J neurointerventional Surg. 2022;14(11):1084\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQuan T, Gai Y, Feng X, Saleme S, Liu B, Zhang X, Guan S. Outcomes of flow diversion in intracranial aneurysms accompanied by parent artery stenosis. Journal of NeuroInterventional Surgery; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGory B, Berge J, Bonaf\u0026eacute; A, et al. Flow Diverters for Intracranial Aneurysms: The DIVERSION National Prospective Cohort Study. Stroke. 2019;50:3471\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDi Maria F, Pistocchi S, Claren\u0026ccedil;on F, et al. Flow Diversion versus Standard Endovascular Techniques for the Treatment of Unruptured Carotid-Ophthalmic Aneurysms. AJNR Am J Neuroradiol. 2015;36:2325\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhogal P, AlMatter M, B\u0026auml;zner H, Ganslandt O, Henkes H, Aguilar P\u0026eacute;rez M. Flow diversion for the treatment of MCA bifurcation aneurysms\u0026mdash;a single centre experience. Front Neurol. 2017;8:20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eT\u0026uuml;re U, Yaşargil MG, Al-Mefty O, Yaşargil DC. Arteries of the insula. J Neurosurg. 2000;92:676\u0026ndash;87. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/jns.2000.92.4.0676\u003c/span\u003e\u003cspan address=\"10.3171/jns.2000.92.4.0676\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaleme S, Iosif C, Ponomarjova S, Mendes G, Camilleri Y, Caire F, Mounayer C. Flow-diverting stents for intracranial bifurcation aneurysm treatment. Neurosurgery. 2014;75(6):623\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKorkmazer B, Karaman AK, Ustundag A, Arslan S, Kızılkılı\u0026ccedil; O, Ko\u0026ccedil;er N, Islak C. Magnetic resonance perfusion imaging findings following flow diversion in patients with complex middle cerebral artery bifurcation aneurysms: a single-center analysis regarding the jailed cortical branches. J NeuroInterventional Surg. 2024;16(1):8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQuan T, Gai Y, Feng X, Saleme S, Liu B, Zhang X, Guan S. Outcomes of flow diversion in intracranial aneurysms accompanied by parent artery stenosis. Journal of NeuroInterventional Surgery; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIosif C, Mounayer C, Yavuz K, Saleme S, Geyik S, Cekirge HS, Saatci I. Middle cerebral artery bifurcation aneurysms treated by extrasaccular flow diverters: midterm angiographic evolution and clinical outcome. Am J Neuroradiol. 2017;38(2):310\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShapiro M, Shapiro A, Raz E, Becske T, Riina H, Nelson PK. Toward better understanding of flow diversion in bifurcation aneurysms. Am J Neuroradiol. 2018;39(12):2278\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen SQ, Li L, Gao BL, Wu QW, Shao QJ, Wang ZL, Li TX. Safety and effect of pipeline flex embolization device for complex unruptured intracranial aneurysms. Sci Rep. 2023;13(1):4570.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMakhambetov Y, Maidan A, Nurimanov C, Kaliyev A, Kunakbayev B, Nurakay N, Makhambetov N. Safety and efficacy of flow diverter stents in the treatment of bifurcation cerebral aneurysms: single-center experience. Diagn Interventional Radiol. 2025;31(4):366.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHellstern V, Brenner N, Cimpoca A, Albina Palmarola P, Henkes E, Wendl C, Henkes H. Flow diversion for unruptured MCA bifurcation aneurysms: comparison of p64 classic, p64 MW HPC, and p48 MW HPC flow diverter stents. Front Neurol. 2024;15:1415861.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMilewski K, Zurakowski A, Pajak J, Pajak-Zielinska E, Liszka L, Buszman PP, Buszman PE. Comparison of thin-strut cobalt-chromium stents and stainless steel stents in a porcine model of neointimal hyperplasia. Med Sci monitor: Int Med J experimental Clin Res. 2010;16(1):BR40\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJun YJ, Hwang DK, Lee HS, Kim BM, Park KD. Flow diverter performance comparison of different wire materials for effective intracranial aneurysm treatment. Bioengineering. 2024;11(1):76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOliver AA, Senol YC, Bilgin C, Schaffer JE, Kadirvel R, Kallmes DF, Wainwright JM. Intraluminal flow diverter design primer for neurointerventionalists. Am J Neuroradiol. 2024;45(4):365\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Middle cerebral artery stenosis, Middle cerebral bifurcation aneurysm, Flow diverter, Transient ischemic attack(TIA), Digital subtraction angiography (DSA)","lastPublishedDoi":"10.21203/rs.3.rs-7339773/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7339773/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe effective treatment of middle cerebral artery (MCA) bifurcation aneurysms remains challenging and is often prone to complications when treating aneurysms in these sites. FDs treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. At the same time, the FDs demonstrated satisfactory performance in terms of periprocedural complications, favorable clinical outcomes, and complete occlusion on follow-up imaging in the management of intracranial aneurysms accompanied by parent artery stenosis. However, there is little data to support FDs treatment for middle cerebral bifurcation aneurysms combined with parent artery stenosis.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e\u003cp\u003eA 54-year-old male patient came to hospital for treatment due to repeated left limb weakness and had a history of hypertension for more than 10 years. Complete digital subtraction angiography (DSA) confirmed that there was local severe stenosis in the M1 segment of the right middle cerebral artery, and an aneurysm formed at the distal bifurcation. The preoperative diagnosis was TIA and an aneurysm in the middle bifurcation of the right side of the brain. The patient was treated with balloon dilation and injection of a flow-diverter device for the treatment of bifurcation aneurysm and stenosis. Patients should take medication regularly before and after surgery and have regular follow-up. During the 49-month postoperative follow-up, the patient did not experience ischemic events or aneurysm recurrence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eFDs\u0026rsquo; treatment is feasible in patients with bifurcation aneurysms of the middle cerebral artery with stenosis of the parent artery, and for bifurcation aneurysms, the safety and efficacy of FDs\u0026rsquo; treatment is comparable to other available endovascular options. At the same time, for parent artery stenosis, it has shown satisfactory performance in terms of perioperative complications, good clinical outcomes, and complete occlusion on subsequent imaging.\u003c/p\u003e","manuscriptTitle":"Case Report: PipelineTM Flex flow diverter for an unruptured MCA Bifurcation Aneurysm and parent artery stenosis with 49 months follow-up","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 09:29:31","doi":"10.21203/rs.3.rs-7339773/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-16T04:10:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"271314273108151470480985250299821802443","date":"2025-09-11T07:25:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-11T07:17:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-12T12:23:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-11T03:48:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-11T03:47:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-08-10T15:32:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a5eb397d-63e8-4ae8-9927-daf050fb87d7","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T09:29:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-22 09:29:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7339773","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7339773","identity":"rs-7339773","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}