Delayed Treatment (≥5 Days) by Flow Diversion of Ruptured Blister-Like Cerebral Aneurysms: Case Series of 8 Consecutive Patients

Stent-assisted Coiling vs. Flow Diverter for Treating Blood Blister-like Aneurysms : A Proportion Meta-analysis

PURPOSE

Blood blister-like aneurysms (BBAs) are rare vascular lesions and a therapeutic challenge. Although endovascular treatment of BBA is a promising approach, the optimal treatment remains controversial. The purpose of this study was to compare the safety and efficacy of stent-assisted coiling (SAC) and flow diverter (FD) in the management of BBAs.

METHODS

A proportion meta-analysis including a published series of BBAs treated with endovascular approaches from 2009 to 2020 including SAC and FD was performed by searching English language studies via MEDLINE and EMBASE.

RESULTS

The 32 studies included 16 based on SAC and 16 involving FD. The long-term complete occlusion rate was higher in FD (89.26%, 95% confidence interval, CI 82.93-94.26%, I² = 14.42%) than in SAC (70.26%, 95% CI 56.79-82.13%, I² = 70.60%). The rate of aneurysm recanalization was lower in FD (4.54%, 95% CI 1.72-8.16%, I² = 0%) than in SAC (25.38%, 95% CI 14.44-38.19%, I² = 67.31%). Rates of mortality, favorable functional outcome, procedural complications, and rebleeding showed no differences between the two procedures.

CONCLUSION

In a proportion meta-analysis comparing FD with SAC, the FD was associated with more favorable angiographic outcomes but similar complications and clinical outcomes.

Application of the Willis Covered Stent in the Treatment of Blood Blister-Like Aneurysms: A Single-Center Experience

Objective

To evaluate the effectiveness of the Willis covered stent (WCS) in the treatment of ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA).

Method

The clinical data of 16 patients consecutively treated with WCSs from December 2015 to January 2019 were retrospectively analyzed. Clinical data and angiographic findings were analyzed by two experienced neuroradiologists and neurosurgeons, including age, sex, Hunt and Hess (H&H) grade at admission, modified Rankin scale (mRS) score, aneurysm size, and location, the diameter of the patent artery in proximal and distal ends, stent size, rate of aneurysm occlusion, procedure-related complications, and follow-up.

Results

All the 16 patients (five males, 11 females) with ICA BBAs underwent WCS deployment successfully. The median age was 49 years (range, 29–72). All patients had complete aneurysm occlusion on immediate postoperative angiography. Anterior choroidal artery (AChA) was occluded in one patient accidentally while no obvious neurological dysfunction was observed. However, this patient underwent subarachnoid hemorrhage 1 day after the treatment; endoleak and aneurysm recurred, and the patient died 10 days later. Therefore, the effective rate of WCS treatment was 93.8% (15/16), and procedure-related complications rate was 6.3% (1/16). Moreover, one patient was urgently treated because of accidental aneurysm rupture after anesthesia, and external ventricular drainage was then performed postoperatively. Another patient developed coma and hemiplegia 3 days after treatment, with emergency angiography showing in-stent thrombosis and ICA occlusion which was recanalized with arterial rt-PA thrombolysis; the patient recovered completely. The clinical follow-up period was 3–30 months in 14 patients. The mRS scores were 0 in 12 patients (85.7%) and 4 in 1 case (7.1%), while 1 patient (7.1%) died 6 months postoperatively for unknown reasons. Angiographic follow-up was performed in 13 patients, and no recurrence was observed. However, ICA occlusion without neurological deficit was observed in one patient.

Conclusion

Based on careful preoperative evaluation, appropriate WCS size selection, and precise surgical operation, WCSs may provide an alternative and effective solution for blood BBAs via aneurysm isolation and ICA reconstruction immediately; However, further follow-up studies with larger samples are required.

Flow diversion for acutely ruptured intracranial aneurysms treatment: A retrospective study and literature review

OBJECTIVE

Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent.

MATERIALS AND METHODS

A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20^th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I² value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed.

RESULTS

From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively).

CONCLUSION

Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.

Early Treatment of Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery With Flow Diverters Using Single Antiplatelet Therapy: A Single-Center Experience With Long-Term Follow-Up

Background and Purpose: Blood Blister-like aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities of cerebral aneurysms. FD use in acutely ruptured aneurysms, timing of treatment and antiplatelet regimen are main debate topics in clinical practice when the treatment decision is flow diversion. The aim of this study is to report the safety and efficacy of a single-center FD treatment for ruptured BBAs in the early phase of SAH using the SAPT regimen.

Material and Method: This study involved a retrospective analysis of a prospectively collected database. Records of patients admitted to our clinic and treated by endovascular route on ruptured BBA between January 2013 and December 2020 were reviewed. Ruptured supraclinoid ICA BBAs treated with FD devices with SAPT within 48 h from ictus of SAH are included. BBA of atypical anatomic locations, other endovascular techniques performed, and delayed admissions (>48 h) were excluded from the study. Demographic, clinical and angiographic features of patients and aneurysms, FD types and numbers, periprocedural complications, immediate and follow-up angiographic and clinical outcomes were recorded.

Results: A total of six patients with ruptured BBAs treated via FDs within 48 h and used SAPT were included in the study. The mean age was 41.6 years (range from 34 to 45 years), and four of six patients were female. All patients were treated within 48 h after ictus, and the mean treatment day was 1.33 days. One patient received ticagrelor, and five patients received prasugrel as SAPT for one year after treatment. No procedure-related death and rebleeding were recorded. One (16.7 %) treatment responsive procedure-related complication occurred (transient ischemia). Overall good outcome rate was 83.3%. One patient died due to pneumonia. The immediate control angiograms showed complete occlusions of BBAs in one patient (16.6%). The complete occlusion rate was 100 % for five survivors at the control angiogram. The median follow-up was 49.5 months.

Conclusion: This single-center experience suggests that early treatment (<2 days) within SAH of ruptured BBAs with FDs using SAPT is safe and effective in terms of clinical and radiological long-term outcomes.

Ruptured Intracranial Aneurysms Treated with the Pipeline Embolization Device: A Systematic Review and Pooled Analysis of Individual Patient Data

BACKGROUND

The Pipeline Embolization Device (PED) is a flow-diverting stent for the treatment of intracranial aneurysms and is used off-label for a subset of ruptured aneurysms not amenable to traditional treatment.

PURPOSE

Our aim was to evaluate the safety and efficacy of the PED for treatment of ruptured intracranial aneurysms.

DATA SOURCES

A systematic review of the MEDLINE, EMBASE, and Scopus data bases from January 2011 to March 2020 was performed for articles reporting treatment of ruptured intracranial aneurysms with the PED.

STUDY SELECTION

A total of 12 studies comprising 145 patients with 145 treated aneurysms were included for analysis.

DATA ANALYSIS

Individual patient data were collected. Nonparametric tests were used to compare differences among patients. Logistic regression was used to determine an association with outcome variables.

DATA SYNTHESIS

Mean aneurysm size was 5.9 mm, and most were blister (51.0%) or dissecting (26.9%) in morphology. Three (2.1%) aneurysms reruptured following PED placement. Univariate logistic regression identified larger aneurysm size as a significant predictor of aneurysm rerupture (P = .008). Of patients with radiographic follow-up, 87.5% had complete aneurysm occlusion. Symptomatic neurologic complications occurred in 16.5%.

LIMITATIONS

Analysis was limited by the quality of the included data, most of which were from small case series representing class III medical evidence. No study assessed outcome in a blinded or independently adjudicated manner.

CONCLUSIONS

Most ruptured aneurysms treated with the PED were blister or dissecting aneurysms. Treatment was associated with a rerupture rate of 2.1% and a complete occlusion rate of 87.5%.

Endovascular Treatment of Ruptured Intracranial Blister Aneurysms: A Systematic Review and Meta-analysis

BACKGROUND

Endovascular treatment of blister aneurysms is a promising approach, even though they are vascular lesions challenging to treat due to their angioarchitectural characteristics.

PURPOSE

Our aim was to investigate clinical and radiologic outcomes after endovascular treatment of ruptured blister aneurysms.

DATA SOURCES

PubMed, Ovid MEDLINE, Ovid EMBASE, Scopus, and the Web of Science were screened.

STUDY SELECTION

We performed a comprehensive review of the literature from 2010 to 2019 reporting series of patients with blister aneurysms treated with an endovascular approach.

DATA ANALYSIS

Event rates were pooled across studies using a random effects meta-analysis.

DATA SYNTHESIS

A total of 32 studies reporting on 684 patients (707 aneurysms) were included. Stent placement, stent-assisted coiling, and flow diversion were the most commonly described treatments (282, 256, and 155 patients, respectively). The long-term complete occlusion rate was 76.9% (95% CI, 69.2%-83.9%). The perioperative complication rate was 8.9%, and clinical outcome at final follow-up was mRS <2 in 76.6% (95% CI, 68.2%-84.2%) of patients. The mortality rate was 4.7% (95% CI, 2.30%-7.80%). Among the different techniques, stent-assisted coiling is the one that had the higher rate of immediate occlusion (63.4%); however, the occlusion rate at the final follow-up was comparable among the different techniques.

LIMITATIONS

Different techniques were described and data were reported in a nonhomogeneous way, possibly representing a bias in the present study.

CONCLUSIONS

This study suggests that endovascular treatment of blister aneurysms is associated with good long-term occlusion rates and reasonable complication and mortality rates. There is no consensus on the best endovascular techniques in blister aneurysm management.

Treatment of Ruptured Blister-Like Aneurysms with the FRED Flow Diverter: A Multicenter Experience

BACKGROUND AND PURPOSE

Treatment of ruptured blister-like aneurysms is technically challenging. This study aimed at analyzing the safety and efficacy of the Flow-Redirection Endoluminal Device (FRED) in the treatment of ruptured blister-like aneurysms.

MATERIALS AND METHODS

In a retrospective multicenter study, all patients treated with the FRED due to a ruptured intracranial blister-like aneurysm between January 2013 and May 2019 were analyzed. The primary end points for clinical safety were mRS 0-2 at 6 months after treatment and the absence of major ipsilateral stroke or death. The primary end points for efficacy were the absence of rebleeding after treatment and complete angiographic occlusion according to the O'Kelly-Marotta classification at 6 months after treatment.

RESULTS

In total, 30 patients with 30 ruptured blister-like aneurysms were treated. Immediate complete aneurysm obliteration (O'Kelly-Marotta classification D) with the FRED was achieved in 10 patients (33%). Of the 26 patients with follow-up, complete obliteration was achieved in 21 patients (80%) after 6 months and in 24 patients (92%) in the final follow-up (median, 22 months). Twenty-three patients (77%) achieved mRS 0-2 at 6 months. Major stroke or death occurred in 17%. Two patients died due to pneumonia, and 2 patients died due to infarction following cerebral vasospasm. There was no case of rebleeding after FRED implantation. There was 1 case of delayed asymptomatic stent occlusion.

CONCLUSIONS

Treatment of ruptured blister-like aneurysms with the FRED is safe and effective.

Preliminary Experience with Cangrelor for Endovascular Treatment of Challenging Intracranial Aneurysms

BACKGROUND AND PURPOSE

Cangrelor is a P2Y12 inhibitor that presents the advantage of having a short half-life. Its use may be helpful in the management of antiplatelet therapy for patients with intracranial aneurysms treated by stent-assisted coiling or flow-diverter stents. The purpose of this study was to report early experiences in using cangrelor for such indications.

MATERIAL AND METHODS

From October 2017 to November 2018, 7 consecutive patients (5 females, 2 males, mean age = 56 years) were managed with cangrelor as antiplatelet therapy, combined with aspirin, for stent-assisted coiling embolization and flow-diverter embolization of challenging intracranial aneurysms. Anti-aggregation protocols, including cangrelor, were systematically recorded. Treatment-related complications (minor/major hemorrhagic complications, ischemic complications) as well as clinical and angiographic outcomes (evaluated at 8.7 ± 4.2 and 8.75 ± 10 months, respectively) were retrospectively analyzed.

RESULTS

Of the aneurysms 71.4% (5 out of 7) were ruptured and treated in the acute phase. In one case cangrelor was used as an alternative to clopidogrel in an asymptomatic hemorrhagic complication after stent-assisted coiling for better control of a possible worsening of the intracranial bleeding. Of the patients, 1 (14%) with a complex ruptured MCA aneurysm treated with a flow-diverter stent experienced a severe intracranial hemorrhage, which occurred after switching the cangrelor to ticagrelor and eventually led to death. No hemorrhagic complications under cangrelor were recorded for the six remaining patients. No mRS worsening was observed at discharge, except for the patient who died and six out of the seven patients had a mRS ≤2 at follow-up.

CONCLUSION

Cangrelor is a new antiplatelet therapy with a P2Y12 inhibiting effect, with a rapid onset and offset of action, owing to its short half-life. This cases series presents a pilot experience with promising results in terms of antiplatelet management for challenging intracranial aneurysms treated by stent assisted coiling or flow-diverter stents.