PRECISION ENDOVASCULAR RECONSTRUCTION OF INTRACRANIAL ANEURYSMS: FLOW DIVERSION, INTRASACCULAR FLOW DISRUPTION, SURFACE- MODIFIED DEVICES, AND PATIENT-SPECIFIC DEVICE SELECTION
Background. Endovascular management of intracranial aneurysms has shifted from mechanical filling of the aneurysm sac toward biological reconstruction of the parent artery and controlled modification of intra-aneurysmal hemodynamics. Flow-diverting stents and intrasaccular flow-disruption devices have expanded treatment options for large, giant, fusiform, recurrent, and wide-neck bifurcation aneurysms that are technically challenging for conventional coiling or microsurgical clipping. Contemporary practice increasingly requires selection between parent-vessel flow diversion and intrasaccular treatment rather than universal use of a single implant.Materials and Methods. A structured narrative review was performed using prospective pivotal trials, randomized studies, multicenter registries, long-term device studies, and contemporary clinical investigations available through August 2026. Pipeline, Surpass, FRED/FRED X, Pipeline Shield, Pipeline Vantage, Woven EndoBridge, Contour, and emerging intrasaccular technologies were evaluated. Particular attention was directed toward aneurysm morphology, vessel reconstruction, branch preservation, delayed occlusion, antiplatelet therapy, surface modification, incomplete occlusion, retreatment, ruptured aneurysms, posterior circulation lesions, and device-specific treatment geometry.Results. Flow diversion provides progressive aneurysm exclusion through reduction of inflow, intra-aneurysmal thrombosis, and endothelial reconstruction across the aneurysm neck. Long-term studies demonstrate progressive occlusion after Pipeline and Surpass treatment, although efficacy and complication profiles vary substantially according to aneurysm location and morphology. Small and medium unruptured aneurysms can be treated with high effectiveness in appropriately selected patients, but flow diversion requires a parent artery suitable for implantation and usually mandates antiplatelet therapy. Intrasaccular devices provide a fundamentally different strategy by disrupting flow at or within the aneurysm neck without reconstructing the parent artery. The WEB has demonstrated durable five-year safety and effectiveness for wide-neck bifurcation aneurysms, and prospective data support its use in selected ruptured aneurysms. Newer neck-bridging intrasaccular systems such as Contour and Artisse further expand this concept. Surface-modified flow diverters may reduce device thrombogenicity and facilitate simplified antiplatelet strategies, although routine single- antiplatelet treatment has not yet become a universal standard.Conclusion. Intracranial aneurysm therapy is evolving toward precision device selection based on aneurysm geometry, parent-vessel anatomy, bifurcation architecture, rupture status, branch incorporation, expected healing mechanism, and antiplatelet tolerance. The future objective is not to select the most technologically advanced implant, but to choose the device whose biological mechanism best matches the individual aneurysm.