Patient management after flow diversion for unruptured intracranial aneurysms: A literature review and DELPHI consensus

Authors

• Alexander Stebner, Department of Neuroradiology, University Hospital of Basel, Basel, Switzerland.
• Marie-Sophie Schüngel, Department of Neuroradiology, University Hospital in Halle, Halle, Germany.
• Salome Lou Bosshart, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
• Satoru Fujiwara, Department of Neurology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan.
• Genevieve Milot, Department of Surgery, Université Laval, Québec, Canada.
• David Volders, Department of Radiology, University of Toronto, Toronto, Canada.
• Kazutaka Uchida, Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
• Christine Hawkes, Division of Neurology, Sunnybrook Health Science Centre, Toronto, Canada.
• Petra Cimflova, Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, Bern, Switzerland.
• Manu Moreu, Radiology department, Hospital Clínico San Carlos, Madrid, Spain.
• Isabel Fragata, Department of Neuroradiology, ULS São José, Lisbon, Portugal.
• Alexandra Paul, Department of Neurosurgery, Albany Medical Center Hospital, Albany, United States.
• Umberto Pensato, Department of Neurology, IRCCS Humanitas Research Hospital, Rozzano, Italy.
• Christian Ulfert, Department of Neuroradiologie, University Hospital Heidelberg, Heidelberg, Germany.
• Donald Frei, Colorado Neurological Institute, Denver, United States.
• Pervinder Bhogal, Department of Neuroradiology, Royal London Hospital, London, United Kingdom.
• Joanna Schaafsma, Department of Medical Imaging, University Health Network, Toronto, Canada.
• Sandor Nardai, Center of Neurosurgery and Neurointervention, Semmelweis University, Budapest, Hungary.
• Syed Zaidi, Department of Neurology,, University of Toledo, Toledo, United States.
• Mohammed Almekhlafi, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
• Shahid Nimjee, The Ohio State University Wexner Medical Center, Columbus, United States.
• Pascal Mosimann, Department of Radiology, University of Toronto, Toronto, Canada.
• James Kennedy, John Radcliffe Hospital, Oxford, United Kingdom.
• Jeremy Rempel, Department of Radiology, University of Alberta, Edmonton, Canada.
• Violoza Inoa, Department of Neurology, University of Tennessee Health Science Center, Memphis, United States.
• Shinichi Yoshimura, Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
• Marc Ribo, Department of Neurology, Vall d'Hebron Hospital Universitari, Barcelona, Spain.
• Demetrius Lopes, Advocate Health - MidwestFollow
• John Wong, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
• et al

Recommended Citation

Stebner A, Schüngel MS, Bosshart SL, et al. Patient Management After Flow Diversion for Unruptured Intracranial Aneurysms: a Literature Review and DELPHI Consensus. Clin Neuroradiol. Published online December 19, 2025. doi:10.1007/s00062-025-01600-w

Affiliations

Advocate Illinois Masonic Medical Center

Abstract

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.

Methods: 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.

Results: 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: 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.

Document Type

Article

PubMed ID

41417040