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Lim YC, Song J. Long-Term Outcomes of Ruptured Blood Blister-Like Aneurysms with Multiple (≥2) Overlapping Stents and Coiling: A Single-Center Experience. World Neurosurg 2023; 175:e950-e958. [PMID: 37075893 DOI: 10.1016/j.wneu.2023.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To evaluate the long-term feasibility of multiple overlapping stents (≥2) with or without coiling for treating blood blister-like aneurysms (BBAs). METHODS BBAs treated with stent-assisted coiling or stent-only therapy wasincluded. BBAs with atypical anatomical locations, other endovascular or surgical techniques performed, and delayed treatment (>48 hours) were excluded. Medical records of patients and procedures were retrospectively reviewed. RESULTS Seventeen patients with BBAs were identified, and 15 were treated with stent-assisted coiling and 2 with stent-only therapy. Triple overlapping stents were performed in seven patients, double stents in nine, and a single stent with coiling in 1. One patient experienced in-stent fibrin formation and received intra-arterial tirofiban. Complementary treatment was required in four patients. Three patients were initially treated with double (3/9) and 1 with triple stents (1/7). Three recurred in the acute period (≤6 weeks) and 1 recurred 14 months after treatment. Three of 17 patients with Hunt Hess grade 5 died early. Thirteen patients were available for long-term angiographic follow-up (13.8 ± 8.9 months). Final angiography showed complete aneurysm occlusion in all patients without in-stent stenosis or perforating vessel occlusion. Clinical follow-up data were available for all 14 surviving patients (66.8 ± 40.9 months). Eight patients had favorable outcomes, five had unfavorable outcomes, and 1 died of a subarachnoid hemorrhage-unrelated cause. Delayed infarct or hemorrhage was not documented. CONCLUSIONS Even in the era of flow diverter stents, the use of multiple overlapping stents with or without coiling can be a feasible alternative for treating ruptured BBAs.
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Affiliation(s)
- Yong Cheol Lim
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jihye Song
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Republic of Korea.
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Kim HJ, Lee JM. Long-term follow up of surgical management of blood blister-like aneurysms at non-branching sites of the internal carotid artery. Medicine (Baltimore) 2023; 102:e33371. [PMID: 36961131 PMCID: PMC10036007 DOI: 10.1097/md.0000000000033371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/07/2023] [Indexed: 03/25/2023] Open
Abstract
To describe long-term follow-up of 25 patients who presented with subarachnoid hemorrhages due to blood blister-like aneurysms (BBAs) treated with direct clipping or clip reinforcement with or without direct neck repair. Between June 1993 and July 2009, 25 consecutive patients with ruptured BBAs of the supraclinoid internal carotid artery were retrospectively reviewed. The mean age of patients was 39.5 ± 11.3 years. The mean duration of clinical follow-up was 128.9 months (range, 85-196 months). All aneurysms were located in the supraclinoid portion of the internal carotid artery. The mean aneurysm diameter was 4.04 ± 1.3 mm on intra-operative microscopic field. Tearing of the aneurysmal neck during dissection occurred in 8 (32%) patients. Six of 7 patients with neck tearing underwent direct neck repair. Surgeons treated aneurysms via direct clipping with a Bemsheet® in 5 (20%) patients or by clip reinforcement with a silicone sheet in 20 (80%) patients. Clinical outcomes were favorable (modified Rankin Scale [mRS]: 0-2) in 21 (84%) of 25 patients. Four (16%) patients had an unfavorable outcome (mRS: 3-6). The patient with severe disability (mRS: 4) was treated with clip reinforcement and direct neck repair. Mild stenosis, moderate stenosis, and total occlusion of the parent artery were confirmed in 10 (40%) patients, 6 (24%) patients, and 1 (4%) patient, respectively. Although surgical treatment of BBAs was associated with varying degrees of parent vessel patency loss, long-term follow-up results for more than 10 years showed that direct surgical clipping or clip reinforcement with a silicone sheet appeared to be a curative surgery.
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Affiliation(s)
- Hyeon-Ju Kim
- Department of Neurosurgery, Jeonbuk National University Hospital and Medical School, Jeon-Ju, South Korea
| | - Jong-Myong Lee
- Department of Neurosurgery, Jeonbuk National University Hospital and Medical School, Jeon-Ju, South Korea
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Flow Diverter Device-Assisted Coiling Treatment for Cerebral Blister Aneurysm: A Single-Center Study. Brain Sci 2023; 13:brainsci13030435. [PMID: 36979245 PMCID: PMC10046186 DOI: 10.3390/brainsci13030435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Although endovascular treatment is a promising approach, blood blister-like aneurysms (BBAs) still present treatment challenges. This study aimed to assess the effectiveness and safety of flow diverter device-assisted coiling (FDDAC) for the treatment of BBAs, which are broad based and friable with a high rebleeding risk. Eight patients (five females and three males) who presented with subarachnoid hemorrhages (SAH) due to BBA ruptures between May 2020 and May 2022 were retrospectively enrolled. All patients were treated by flow diverter device (Tubridge) adjunctive coil embolization using a semi-deploying technique. The demographic information, angiographic data, interval between admission and treatment, materials, therapy, clinical outcomes (including periprocedural and intraprocedural mortality and morbidity), and follow-up results of all patients were reviewed. The mean age of the patients with BBAs was 48.5 years (range 31–62 years); aneurysm sizes ranged from 2.2 × 1.7 mm to 4.6 × 3.2 mm, and the median Hunt–Hess score was 3. All aneurysms were completely closed at follow-up, and all 8 patients had excellent clinical outcomes (modified Rankin scores = 0–2) at discharge. Angiograms showed complete aneurysm occlusion after 6 months to 1 year. In addition, there were no cases of re-rupture, re-treatment, or recurrence of the aneurysms. FDDAC is safe to use in patients with BBAs and provides an alternative treatment option for this disease.
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Endovascular Treatment of Ruptured Blood Blister-like Aneurysms Using the LVIS EVO Stents. J Clin Med 2023; 12:jcm12031089. [PMID: 36769737 PMCID: PMC9918215 DOI: 10.3390/jcm12031089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Blood blister-like aneurysms (BBAs) are rare cerebrovascular lesions that face serious challenges in surgical as well as endovascular treatment. In this paper, we present our experience in treating BBAs using the LVIS EVO stents. A total of 10 patients (mean age of 56.1 years) with 13 BBAs, who were admitted to our university hospital between April 2020 and November 2021 with a subarachnoid hemorrhage (SAH) due to aneurysm rupture, were treated using the LVIS EVO stents. Treatment of the BBAs consisted of stent-assisted coiling in four patients and stenting in six patients. The aneurysms were located within ICA (84.6%), VA (7.7%), and MCA (7.7%). Placement of the LVIS EVO stents was successful in all patients. No technical complications were observed. One in-stent thrombotic event occurred during the procedure. MRA for one-year follow-up was performed in nine patients. One patient died (Hunt and Hess Grade IV). LVIS EVO stents may be a beneficial treatment option for BBAs, as they provide high occlusion rates. However, the long-term efficacy remains uncertain.
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Stent-assisted Coiling vs. Flow Diverter for Treating Blood Blister-like Aneurysms : A Proportion Meta-analysis. Clin Neuroradiol 2022; 32:889-902. [PMID: 35403855 DOI: 10.1007/s00062-022-01160-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/09/2022] [Indexed: 12/15/2022]
Abstract
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.
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Qi Y, Xu T, Jiang C, Wang Y, Liu H. Application of the Willis covered stent in the treatment of internal carotid artery blood blister-like aneurysms. Neurosurg Rev 2021; 45:1513-1519. [PMID: 34657974 DOI: 10.1007/s10143-021-01666-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/16/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
The optimal treatment for blood blister-like aneurysm (BBA) has not yet been determined, and BBA has a high recurrence rate after stent-assisted embolization. The purpose of the present study was to evaluate the safety and feasibility of patients with BBA rupture in the acute phase or patients with BBA who have recurrence after stent-assisted coil embolization. Eight patients (8 women, mean age 50.3 ± 3.7 years) who presented with ruptured BBA or recurrence BBA that had been treated by stent-assisted embolization (5 patients after primary treatment of stent-assisted embolization) were retrospectively reviewed. Clinical follow-up was performed at 1 year after endovascular treatment. All patients were successfully treated with the WCS, and immediate postoperative angiography showed that the aneurysms were completely isolated. The ophthalmic artery was covered by WCS in one patient; however, this patient did not show any clinical visual field or vision symptoms. Procedure-related complications such as aneurysm rupture, vasospasm, acute thrombosis, or thromboembolism did not occur in any case. All patients were followed up for 1 year after endovascular treatment, and they were in good condition without recurrence. One patient developed delayed bleeding at the right temporal lobe. All patients had good clinical prognosis (modified Rankin Scale score ≤ 2). WCS implantation may be a safe and feasible strategy for patients with BBA rupture in the acute phase and patients with BBA who have recurrence after stent-assisted coil embolization and is a promising option worth exploring.
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Affiliation(s)
- Yi Qi
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Tao Xu
- Department of Interventional Medicine, Beijing Chaoyang Integrative Medicine Emergency Medical Center, Beijing, China
| | - Chuhan Jiang
- Department of Interventional Neuroradiology, Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - He Liu
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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Nasra M, Mitreski G, Kok HK, Maingard J, Slater LA, Russell JH, Hall J, Chong W, Jhamb A, Brooks DM, Asadi H. Contemporary Treatment of Intracranial Blood Blister Aneurysms - A Systematic Review. J Stroke Cerebrovasc Dis 2021; 30:105968. [PMID: 34271273 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/14/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Blood blister aneurysms (BBAs) are rare aneurysms affecting non-branched points of intracerebral arteries. Due to their small size and fragility, BBAs are prone to rupture, and can be challenging to diagnose and treat. Several treatment options have been suggested yet there is no consensus regarding the best modality to reduce morbidity and mortality. MATERIALS AND METHODS A systematic review of the literature was conducted searching for articles discussing the treatment of BBAs. Inclusion criteria included: articles published between January 2010 and August 2020, English language, with each paper including at least 15 patients. Studies included required detailed reporting of patient demographics, treatment, and patient outcomes (including complications, recurrence, neurologic functional status, and mortality). RESULTS AND DISCUSSION A total of 25 studies with 883 patients were included. Most were female (n = 594, 67.3%) and aneurysms were overwhelmingly located in the supraclinoid internal carotid artery (99%). Aneurysms were variable in size and mostly presented with subarachnoid haemorrhage. Endovascular treatment (n = 518, 58.7%) was more common than microsurgery (n = 365, 41.1%) while only 2 patients were managed conservatively. Complications were more common in patients treated microsurgically. Microsurgical procedures had an unfavorable outcome (mRS 4-6, GOS 1-3) rate of 27.8% (n = 100/360) while that of endovascular procedures was 14.7% (n = 70/477). Endovascular procedures had a lower mortality rate than microsurgical interventions (8.4% vs 11%). CONCLUSION This review demonstrates that endovascular treatment of blood blister aneurysm has reduced morbidity and mortality when compared with microsurgical treatment. Small sample sizes and substantial study heterogeneity makes strong conclusions difficult.
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Affiliation(s)
- Mohamed Nasra
- Melbourne School of Medicine, University of Melbourne, Parkville, Victoria, Australia.
| | - Goran Mitreski
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Northern Hospital, Epping, Victoria, Australia; School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Julian Maingard
- School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia; Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia
| | - Lee-Ann Slater
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Jonathan Hall
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia; Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Winston Chong
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia; School of Medicine, Monash University, Clayton, Victoria, Australia
| | - Ashu Jhamb
- Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia
| | - Duncan Mark Brooks
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia; School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hamed Asadi
- Department of Radiology, Interventional Neuroradiology Service, Austin Health, Heidelberg, Victoria, Australia; School of Medicine-Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia; Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Clayton, Victoria, Australia; Department of Interventional Radiology, St Vincent's Health Australia, Fitzroy, Victoria, Australia; Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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Sanchez VE, Haider AS, Rowe SE, Wahood W, Sagoo NS, Ozair A, El Ahmadieh TY, Kan P, Johnson JN. Comparison of Blister Aneurysm Treatment Techniques: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 154:e82-e101. [PMID: 34224880 DOI: 10.1016/j.wneu.2021.06.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Blood blister aneurysms are small, thin-walled, rapidly growing side-wall aneurysms that have proved particularly difficult to treat, and evidence-based guidance for treatment strategies is lacking. A systematic review and meta-analysis was performed to aggregate the available data and compare the 3 primary treatment modalities. METHODS We performed a comprehensive literature search according to PRISMA guidelines followed by an indirect meta-analysis that compares the safety and efficacy of surgical, flow-diverting stents (FDS), and other endovascular approaches for the treatment of ruptured blood blister aneurysms. RESULTS A total of 102 studies were included for quantitative synthesis, with sample sizes of 687 treated surgically, 704 treated endovascularly without FDS, and 125 treated via flow diversion. Comparatively, FDS achieved significantly reduced rates of perioperative retreatment compared with both surgical (P = 0.025) and non-FDS endovascular (P < 0.001). The FDS subgroup also achieved a significantly lower incidence of perioperative rebleed (P < 0.001), perioperative hydrocephalus (P = 0.012), postoperative infarction (P = 0.002), postoperative hydrocephalus (P < 0.001), and postoperative vasospasm (P = 0.002) compared with those patients in the open surgical subgroup. Although no significant differences were found among groups on the basis of functional outcomes, angiographic outcomes detailed by rates of radiographic complete occlusion were highest for surgical (90.7%, 262/289) and FDS (89.1%, 98/110) subgroups versus the non-FDS endovascular subgroup (82.7%, 268/324). CONCLUSIONS Flow diversion seems to be an effective treatment strategy for ruptured blood blister aneurysms, with lower rates of perioperative complications compared with surgical and other endovascular techniques, but studies investigating long-term outcomes after flow diversion warrant further study.
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Affiliation(s)
- Victoria E Sanchez
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ali S Haider
- Department of Neurosurgery, Texas A&M University College of Medicine, Bryan, Texas, USA
| | - Scott E Rowe
- Department of Surgery, Nova Southeastern University College of Osteopathic Medicine, Davie, Florida, USA
| | - Waseem Wahood
- Department of Surgery, Nova Southeastern University College of Allopathic Medicine, Davie, Florida, USA
| | - Navraj S Sagoo
- Department of Orthopaedic Surgery, University of Texas Medical Branch School of Medicine, Galveston, Texas, USA
| | - Ahmad Ozair
- Department of Neurosurgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Tarek Y El Ahmadieh
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA.
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Roh H, Kim J, Suh SI, Kwon TH, Yoon W. Is Stent-Assisted Coil Embolization for the Treatment of Ruptured Blood Blister-Like Aneurysms of the Supraclinoid Internal Carotid Artery Effective? : An Analysis of Single Institutional Experience with Pooled Data. J Korean Neurosurg Soc 2021; 64:217-228. [PMID: 33715324 PMCID: PMC7969050 DOI: 10.3340/jkns.2020.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/17/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Given the high risk of rebleeding and recurrence of blood blister-like aneurysms (BBAs), we treated ruptured BBAs of the internal carotid artery (ICA) with stent-assisted coil embolization (SAC). This study aimed to evaluate the efficacy and safety of SACs.
Methods We retrospectively reviewed clinical and radiological data from eight patients with ruptured BBAs of the supraclinoid ICA. The modified Rankin Scale (mRS) was used to assess clinical outcomes, while radiological outcomes were evaluated on angiographs. For a pooled analysis, data from literature reporting the outcomes of ruptured BBAs treated with SAC were collected and analyzed in conjunction with our data.
Results In our cohort, the mean Raymond classification score was 1.57±0.53 immediately after initial endovascular treatment. There were no perioperative complications or rebleeding events during the follow-up period. The mean mRS score at patient discharge was 1.00±0.81 and improved to 0.28±0.48 by the last follow-up day. The recurrence rate was 25% with an asymptomatic presentation and successful treatment with multiple stent insertion. Pooled analysis of 76 cases of SAC revealed a complete occlusion rate immediately after treatment of 54.8%, rebleeding rate 7.94%, and recurrence rate 24.2%. Good clinical outcomes with mRS score 0–2 were observed in 89.9% by the last clinical follow-up. Total mortality rate was 7.7%.
Conclusion This treatment appears to not only minimize the hemodynamic burden on the fragile dome specific to this type of aneurysm, but also provides an opportunity for safe and effective treatment in recurrent cases.
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Affiliation(s)
- Haewon Roh
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Junwon Kim
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang-Il Suh
- Department of Radiology, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Taek-Hyun Kwon
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Wonki Yoon
- Department of Neurosurgery, Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Aihara M, Shimizu T, Naito I, Miyamoto N, Yamaguchi R, Aishima K, Sato K, Shintoku R, Ohtani T, Okano M, Tsukada A, Yoshimoto Y. Endovascular Treatment Strategy and Clinical Outcomes for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery Using Low-Profile Visualized Intraluminal Support Stent. World Neurosurg 2021; 149:e146-e153. [PMID: 33621674 DOI: 10.1016/j.wneu.2021.02.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/13/2021] [Accepted: 02/13/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVE It is challenging to safely treat blood blister-like aneurysms (BBAs) of the internal carotid artery. Endovascular surgery has been reported, but the optimal strategy is yet to be established. We report our endovascular treatment strategy using the Low-profile Visualized Intraluminal Support (LVIS) stent. METHODS Twelve patients with ruptured BBAs including 1 patient with 2 separate aneurysmal bulges were treated from December 2017 to January 2020. Single LVIS stent-assisted coil embolization was performed as the initial treatment. If the coil could not be placed in the aneurysm, or follow-up angiography showed persistent filling or regrowth of the aneurysm, a second LVIS stent was deployed as an overlapping stent. Clinical characteristics, treatment details, and clinical outcomes were retrospectively examined. RESULTS Single stent-assisted coiling was performed in 8 patients (69%), 2 overlapping stents with coiling in 1 (8%), a single stent in 2 (15%), and 2 overlapping stents in 2 (15%). Three patients with persistent filling or regrowth of the aneurysm were re-treated with overlapping stents. Follow-up angiography confirmed complete occlusion in 12 aneurysms (92%). No re-rupture occurred. Postoperative symptomatic ischemia was confirmed in 4 patients (33%), and all 4 patients suffered severe subarachnoid hemorrhage. Modified Rankin scale was 0-2 in 8 patients (67%). CONCLUSIONS LVIS stent-assisted coil embolization is effective in preventing re-rupture of BBAs. However, the morphology of the aneurysm may change within a short period, so careful angiographic follow-up is needed. Appropriate preoperative antiplatelet administration and optimal timing of the treatment may reduce the risk of postoperative ischemic complication.
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Affiliation(s)
- Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Isao Naito
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Naoko Miyamoto
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kaoru Aishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Koji Sato
- Department of Neurosurgery, National Hospital Organization Takasaki General Medical Center, Takasaki, Gunma, Japan
| | - Ryosuke Shintoku
- Department of Neurosurgery, Fukaya Red Cross Hospital, Fukaya, Saitama, Japan
| | - Toshiyuki Ohtani
- Department of Neurosurgery, Fukaya Red Cross Hospital, Fukaya, Saitama, Japan
| | - Mitsuko Okano
- Department of Neurosurgery, Hokushin General Hospital Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Nakano, Nagano, Japan
| | - Akihiro Tsukada
- Department of Neurosurgery, Hokushin General Hospital Nagano Prefectural Federation of Agricultural Cooperatives for Health and Welfare, Nakano, Nagano, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Scerrati A, Visani J, Flacco ME, Ricciardi L, Trungu S, Raco A, Dones F, De Bonis P, Sturiale CL. Endovascular Treatment of Ruptured Intracranial Blister Aneurysms: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2020; 42:538-545. [PMID: 33361375 DOI: 10.3174/ajnr.a6924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 09/29/2020] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- A Scerrati
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy.,Departments of Morphology, Surgery, and Experimental Medicine (A.S., P.D.B.)
| | - J Visani
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy
| | - M E Flacco
- Medical Sciences (M.E.F.), University of Ferrara, Ferrara, Italy
| | - L Ricciardi
- Unità operativa di Neurochirurgia (L.R., S.T.), Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Lecce, Italy .,Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - S Trungu
- Unità operativa di Neurochirurgia (L.R., S.T.), Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Lecce, Italy.,Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - A Raco
- Unità operativa complessa di Neurochirurgia (L.R., S.T., A.R.), Dipartimento di Neuroscienze Salute Mentale e Organi di Senso, Azienda Ospedaliera Sant'Andrea, Sapienza, Rome, Italy
| | - F Dones
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy
| | - P De Bonis
- From the Department of Neurosurgery (A.S., J.V., F.D., P.D.B.), S. Anna University Hospital, Ferrara, Italy.,Departments of Morphology, Surgery, and Experimental Medicine (A.S., P.D.B.)
| | - C L Sturiale
- Department of Neurosurgery (C.L.S.), Fondazione Policlinico Universitario A. Gemelli Istituto di ricovero e cura a carattere scientifico, Rome, Italy
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12
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Kuwayama K, Nakata A, Furuno Y, Hisaoka S, Matsumoto K. Double LVIS Jr. Stenting of a Ruptured Proximal Anterior Inferior Cerebellar Artery Aneurysm: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:339-345. [PMID: 37501903 PMCID: PMC10370979 DOI: 10.5797/jnet.cr.2020-0091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/26/2020] [Indexed: 07/29/2023]
Abstract
Objective We report a case of ruptured aneurysm at the anterior pontine segment of the anterior inferior cerebellar artery (AICA) which re-ruptured after stent placement and was treated by overlapping stenting. Case Presentation A 53-year-old woman presented with headache. CT demonstrated subarachnoid hemorrhage. DSA revealed no evident source of bleeding. On day 10, she complained of sudden headache and CT demonstrated re-bleeding. On repeated DSA, an aneurysm at the anterior pontine segment of the right AICA was found. An LVIS Jr. stent was deployed at the right AICA including the aneurysm. On postoperative day 23, the aneurysm ruptured again. Another LVIS Jr. stent was deployed at the same area. On day 56, she was discharged home without neurological deficit. Conclusion Intracranial aneurysms not indicated for coil embolization or parent artery occlusion are difficult to treat. Overlapping stenting may be a treatment option for such aneurysms.
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Affiliation(s)
- Kazuyuki Kuwayama
- Department of Neurosurgery, Japan Community Health Care Organization Kobe Central Hospital, Kobe, Hyogo, Japan
| | - Akihiro Nakata
- Department of Neurosurgery, Japan Community Health Care Organization Kobe Central Hospital, Kobe, Hyogo, Japan
| | - Yuichi Furuno
- Department of Neurosurgery, Japan Community Health Care Organization Kobe Central Hospital, Kobe, Hyogo, Japan
| | - Satoshi Hisaoka
- Department of Neurosurgery, Japan Community Health Care Organization Kobe Central Hospital, Kobe, Hyogo, Japan
| | - Keigo Matsumoto
- Department of Neurosurgery, Japan Community Health Care Organization Kobe Central Hospital, Kobe, Hyogo, Japan
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13
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Using overlapping low-profile visualized intraluminal support stent-assisted coil embolization for treating blood blister-like aneurysms of the internal carotid artery. Neurosurg Rev 2020; 44:1053-1060. [PMID: 32240447 DOI: 10.1007/s10143-020-01284-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/22/2020] [Accepted: 03/09/2020] [Indexed: 12/16/2022]
Abstract
Blood blister-like aneurysm (BBA) of the internal carotid artery (ICA) is highly challenging to treat owing to its variable morphology and tendency for rupture and regrowth. In this study, we attempted to discuss the key techniques for overlapping low-profile visualized intraluminal support (LVIS) stent-assisted coil embolization, which is used for treating BBAs in our center. Clinical characteristics, endovascular treatment details, outcomes, and follow-up results of 13 patients with BBA treated at our center were retrospectively evaluated in this study. Overlapping LVIS stent-assisted coil embolization was successfully performed in all 13 patients of ruptured BBAs located in the ICAs. Recurrence of aneurysm was observed in 4 cases (30.8%) during the angiographic follow-up; in 2 of these cases, spontaneous healing was observed after discontinuation of antiplatelet therapy. Further, 2 patients with recurrence underwent endovascular treatment with complete obliteration of the aneurysm in one and occlusion of the parent artery after Onyx embolization and stent placement in the other. The overall obliteration rate of the BBAs was 92.3% (12/13). One patient (7.7%) developed intraoperative rupture of the aneurysm with coils protruding outside; however, no severe hemorrhage or neurological dysfunction occurred owing to timely embolization. Overlapping LVIS stent-assisted coil embolization is effective for management of BBA of the ICA. Appropriate adjustment in antiplatelet therapy may improve healing in recurrent cases.
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14
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Wu YQ, Li LZ, Wang ZY, Zhang T, Xu M, Cheng MX. Endovascular Intervention with a Low-profile Visualized Intraluminal Support Stent Versus Surgical Clipping for Blood Blister-like Aneurysms : A Retrospective Study. Clin Neuroradiol 2020; 31:417-424. [PMID: 32086545 DOI: 10.1007/s00062-020-00886-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 02/03/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Blood blister-like aneurysms (BBAs) have a high risk of early recurrence and postoperative rebleeding. This study compared the clinical outcomes and complications between endovascular intervention with low-profile visualized intraluminal support (LVIS) stent-assisted coiling and the surgical clipping in patients with BBAs. METHODS This retrospective study enrolled 39 patients with BBAs who underwent endovascular intervention with LVIS stent-assisted coiling (n = 21) or surgical clipping (n = 18) between January 2013 and July 2018. Primary outcomes were mortality and modified Rankin scale (mRS). Secondary outcomes were hospital stay, intensive care unit (ICU) stay and operation parameters. Complications were also retrospectively collated. RESULTS At baseline, the two groups were well balanced in patient characteristics. The hospital stays, ICU stays, operation time and intraoperative infusion volume were all significantly lower in LVIS group than that in clipping group (p < 0.05). A second operation was performed in 6 cases in the clipping group but none in the LVIS group (p = 0.006). The mean mRS score in the LVIS group was significantly lower than that of the clipping group both at hospital discharge and final follow-up (p < 0.001). Adverse outcomes occurred in 1 case in LVIS group and 7 in clipping group, with significant difference (p = 0.015). Complications were reported in 8 cases in LVIS group and 16 cases in clipping group, with significant difference (p < 0.001). CONCLUSION The endovascular intervention with LVIS stent-assisted coiling has better prognosis than surgical clipping. It decreased the risk of a second operation and procedure-related complications compared with surgical clipping.
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Affiliation(s)
- Ya-Qiu Wu
- Department of Neurosurgery Critical Care Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32, West 2nd Section, First Ring Road, Qingyang District, Chengdu, 610072, China
| | - Li-Zhi Li
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32, West 2nd Section, First Ring Road, Qingyang District, 610072, Chengdu, China
| | - Zhen-Yu Wang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32, West 2nd Section, First Ring Road, Qingyang District, 610072, Chengdu, China
| | - Tian Zhang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32, West 2nd Section, First Ring Road, Qingyang District, 610072, Chengdu, China
| | - Min Xu
- Department of Neurosurgery Critical Care Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32, West 2nd Section, First Ring Road, Qingyang District, Chengdu, 610072, China
| | - Mei-Xiong Cheng
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, No. 32, West 2nd Section, First Ring Road, Qingyang District, 610072, Chengdu, China.
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15
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Kaschner MG, Petridis A, Turowski B. Single-center experience with the new generation Derivo Embolization Device in ruptured dissecting and blister aneurysms. Acta Radiol 2020; 61:37-46. [PMID: 31166695 DOI: 10.1177/0284185119852731] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Treatment of ruptured dissecting and blister aneurysms is technically challenging with potentially high morbidity and mortality. The Derivo Embolisation Device (Derivo) is a flow diverter stent designed for the treatment of intracranial aneurysms. Purpose To assess the safety and feasibility of the Derivo in the treatment of ruptured dissecting and blister aneurysms. Material and Methods We retrospectively analyzed all patients with ruptured dissecting and blister aneurysms treated with the Derivo between February 2016 and July 2018. Procedural details, complications, morbidity within 30 days, and angiographic aneurysm occlusion rates, initially and after six months, were assessed. Results In 10 patients 11 ruptured dissecting and blister aneurysms were treated with 12 Derivos as monotherapy. No aneurysm rebleeding was observed at follow-up. One treatment-related complication occurred including a coil perforation of an additionally treated aneurysm. One patient died due to brain edema. Initial digital subtraction angiography revealed complete (O’Kelly–Marotta [OKM] classification D) and favorable (OKM D+C) occlusion rate in three aneurysms. Six-month follow-up for digital subtraction angiography and clinical evaluation was available in 6/9 patients with complete (OKM D) occlusion in all aneurysms (6/6). Favorable (modified Rankin Scale [mRS] ≤ 2) and moderate (mRS 3) clinical outcome after a mean follow-up of 10 months was observed in six and two patients, respectively. Conclusion Endovascular treatment with the Derivo in ruptured dissecting and blister aneurysms revealed a sufficient initial division of aneurysms from the circulation without rebleeding. The Derivo is associated with high procedural and clinical short-term safety.
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Affiliation(s)
- Marius Georg Kaschner
- University Düsseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Germany
| | | | - Bernd Turowski
- University Düsseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Germany
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16
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Kaschner MG, Kraus B, Petridis A, Turowski B. Endovascular treatment of intracranial 'blister' and dissecting aneurysms. Neuroradiol J 2019; 32:353-365. [PMID: 31271334 DOI: 10.1177/1971400919861406] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Blister and dissecting aneurysms may have a different pathological background but they are commonly defined by instability of the vessel wall and bear a high risk of fatal rupture and rerupture. Lack of aneurysm sack makes treatment challenging. PURPOSE The purpose of this study was to assess the safety and feasibility of endovascular treatment of intracranial blister and dissecting aneurysms. METHODS We retrospectively analysed all patients with ruptured and unruptured blister and dissecting aneurysms treated endovascularly between 2004-2018. Procedural details, complications, morbidity/mortality, clinical favourable outcome (modified Rankin Scale ≤2) and aneurysm occlusion rates were assessed. RESULTS Thirty-four patients with endovascular treatment of 35 aneurysms (26 dissecting aneurysms and 9 blister aneurysms) were included. Five aneurysms were treated by parent vessel occlusion, and 30 aneurysms were treated by vessel reconstruction using stent monotherapy (n = 9), stent-assisted coiling (n = 7), flow diverting stents (n = 13) and coiling + Onyx embolization (n = 1). No aneurysm rebleeding and no procedure-related major complications or deaths occurred. There were five deaths in consequence of initial subarachnoid haemorrhage. Complete occlusion (79.2%) was detected in 19/24 aneurysms available for angiographic follow-up, and aneurysm recurrence in 2/24 (8.3%). The modified Rankin Scale ≤2 rate at mean follow-up of 15.1 months was 64.7%. CONCLUSION Treatment of blister and dissecting aneurysms developed from coil embolization to flow diversion with multiple stents to the usage of flow diverting stents. Results using modern flow diverting stents encourage us to effectively treat this aneurysm entity endovascularly by vessel reconstruction. Therefore, we recommend preference of vessel reconstructive techniques to parent vessel occlusion.
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Affiliation(s)
- Marius G Kaschner
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Bastian Kraus
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Athanasios Petridis
- 2 Department of Neurosurgery, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Bernd Turowski
- 1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
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17
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Hanihara M, Yoshioka H, Kanemaru K, Hashimoto K, Shimizu M, Nishigaya K, Fukamachi A, Kinouchi H. Long-Term Clinical and Angiographic Outcomes of Wrap-Clipping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery Using Advanced Monitoring. World Neurosurg 2019; 126:e439-e446. [DOI: 10.1016/j.wneu.2019.02.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
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18
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Treatment of Blood Blister–like Aneurysms with Stent-Assisted Coiling: A Retrospective Multicenter Study. World Neurosurg 2019; 126:e486-e491. [DOI: 10.1016/j.wneu.2019.02.076] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/07/2019] [Indexed: 11/21/2022]
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19
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Yan Z, Zheng K, Xiong Y, Lan F, Wang Y, Tan X, Zhong M, Li Z. Intracranial Complex Ruptured Aneurysms Coiled with Overlapping Low-Profile Visualized Intraluminal Support Stents: Another Available Option for Complex Ruptured Intracranial Aneurysms. World Neurosurg 2019; 125:e22-e28. [DOI: 10.1016/j.wneu.2018.12.142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 12/26/2022]
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20
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Surgical Strategies and Clinical Results of Site-Specific Treatment Using High-Flow Bypass for Ruptured Blood Blister–Like Anterior Wall Aneurysms of the Internal Carotid Artery. World Neurosurg 2019; 125:e1247-e1255. [DOI: 10.1016/j.wneu.2019.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/01/2019] [Accepted: 02/02/2019] [Indexed: 11/19/2022]
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21
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Barletta EA, Gaspar RHML, Araújo JFM, Neves MWF, de Aquino JLB, Belsuzarri TAB. Nonsaccular aneurysms: A wide comparison between the four main types. Surg Neurol Int 2019; 10:30. [PMID: 31528368 PMCID: PMC6499464 DOI: 10.4103/sni.sni_138_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 08/20/2018] [Indexed: 11/24/2022] Open
Abstract
Background: The present study aims to present the most important considerations when it comes to patients features, clinical presentation, localization, morphology, pathogenesis, and the best treatment for each type of the nonsaccular aneurysms. Methods: We performed a literature review using PubMed. The search was limited to the studies published in English, from 2010 to 2017. Results: Data about the clinical presentation; the aneurysm pathogenesis, morphology, and localization; the patient features; and about the surgical or endovascular approach were analyzed for the four types of nonsaccular aneurysms presented. Conclusion: All types of nonsaccular aneurysms have a higher prevalence in young adults. Men are more affected by fusiform and mycotic aneurysms while women suffer more with blister-like aneurysms (BLAs). The mycotic and the BLAs affect more the anterior circulation while the fusiform affects more the posterior circulation. Mycotic and blister-like has as its major complication and clinical presentation the hemorrhage; however, the fusiform aneurysms usually present ischemia and/or mass effect. The reconstructive endovascular techniques for all types of nonsaccular aneurysms presented as the treatment with the best outcomes. Among this technique, the flow diversion presented good results in all types of aneurysms and it seems to promote the best outcomes.
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Affiliation(s)
| | | | | | | | | | - Telmo Augusto Barba Belsuzarri
- Medicine Student from Pontifical Catholic University of Campinas, Campinas, SP, Brazil.,Neurosurgery Department from Pontifical Catholic University of Campinas, Campinas, SP, Brazil.,Post-Graduation Department at Pontifical Catholic University of Campinas, Campinas, SP, Brazil
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22
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Delayed Treatment (≥5 Days) by Flow Diversion of Ruptured Blister-Like Cerebral Aneurysms. Clin Neuroradiol 2019; 30:287-296. [DOI: 10.1007/s00062-019-00758-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/08/2019] [Indexed: 11/26/2022]
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23
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Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results. World Neurosurg X 2019; 2:100005. [PMID: 31218280 PMCID: PMC6580898 DOI: 10.1016/j.wnsx.2018.100005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/13/2018] [Indexed: 12/13/2022] Open
Abstract
Background We have been performing the clipping on crossed wrapping (COCW) method using 2 strips of cotton on patients with an internal carotid artery blood blister-like aneurysm (IC-BLA). This method is reliable in preventing the clips from slipping off and the aneurysm walls from being damaged during clipping, and it enables more appropriate and safer clipping. Here we report the technical details of this method and the long-term outcomes of patients receiving this procedure. Methods Fifteen of 1275 (1.5%) patients with a ruptured cerebral aneurysm who received treatment at the Saiseikai Kumamoto Hospital during the period from January 1, 1999, to December 31, 2016, had an IC-BLA. All 15 patients were treated with COCW, except for the first patient, who was treated using a single strip of cotton. The long-term outcome of the treatment was analyzed. Results The mean follow-up period was 74 months. The first patient experienced rerupture of an aneurysm 10 days after the operation. No complications or regrowth of an aneurysm were observed in the remaining 14 patients during the follow-up period, except for 1 patient who received a reoperation for the regrowth of an aneurysm. As the final outcome, the numbers of patients with a Modified Rankin Score of 0, 3, and 6 were 13, 1, and 1, respectively. Conclusions It is suggested that COCW is a treatment that enables safe and long-term management of lesions in IC-BLAs.
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Key Words
- 3D-CTA, Three-dimensional computed tomographic angiography
- AchA, Anterior choroidal artery
- BBA, Blood blister-like aneurysm
- Blood blister-like aneurysm
- COCW, Clipping on crossed wrapping
- COW, Clipping on wrapping
- CT, Computed tomography
- Clipping on crossed wrapping
- Clipping on wrapping
- Direct surgery
- IC, Internal carotid
- IC-BBAs, BBAs of the ICA
- ICA, Internal carotid artery
- Internal carotid artery aneurysm
- PcomA, Posterior communicating artery
- SAH, Subarachnoid hemorrhage
- mRS, Modified Rankin Scale
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24
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Hellstern V, Aguilar-Pérez M, AlMatter M, Bhogal P, Henkes E, Ganslandt O, Henkes H. Microsurgical clipping and endovascular flow diversion of ruptured anterior circulation blood blister-like aneurysms. Interv Neuroradiol 2018; 24:615-623. [PMID: 30001647 PMCID: PMC6259333 DOI: 10.1177/1591019918785911] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/06/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Detection and treatment of blister-like intracranial aneurysms as a source of subarachnoid hemorrhage (SAH) can be challenging. In the past the results of both microsurgical and endovascular treatment were difficult. We present our experience with the treatment of blister-like aneurysms in the acute phase of SAH using microsurgical clipping, endovascular parent vessel occlusion or flow diversion. METHODS A retrospective analysis of the cases of eight consecutive patients presenting in the acute phase after SAH from an intracranial blister aneurysm was performed. The demographic data of the patients, aneurysm characteristics, the clinical results of the treatment and the follow-up examinations were recorded. Procedural safety margins and aneurysm occlusion on follow-up digital subtraction angiography were the main interest of this evaluation. RESULTS Between January 2012 and November 2017 a total of eight ruptured blister aneurysms were treated in our center, six patients endovascularly. Five patients were treated in the acute phase of SAH, four by flow diversion. All endovascular procedures were feasible and no procedure-related complications were observed, especially no recurrent hemorrhage. In the first angiographic follow-up all blood blister-like aneurysms were completely occluded; two of the six patients treated by flow diverter implantation showed mild, transient intimal hyperplasia without clinical symptoms or the need for treatment. CONCLUSIONS Endovascular flow diversion is a viable option in the acute phase after SAH due to the rupture of a blister aneurysm. Implants with reduced thrombogenicity, obviating dual-platelet function inhibition, and flow diverters for vessel bifurcations would extend the indications for this treatment modality.
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Affiliation(s)
- V Hellstern
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar-Pérez
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - M AlMatter
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - P Bhogal
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - E Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
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25
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Zhu D, Yan Y, Zhao P, Duan G, Zhao R, Liu J, Huang Q. Safety and Efficacy of Flow Diverter Treatment for Blood Blister–Like Aneurysm: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 118:e79-e86. [DOI: 10.1016/j.wneu.2018.06.123] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
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26
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Extracranial-Intracranial Bypass for Treatment of Blister Aneurysms: Efficacy and Analysis of Complications Compared with Alternative Treatment Strategies. World Neurosurg 2018; 117:e417-e424. [DOI: 10.1016/j.wneu.2018.06.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 11/24/2022]
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27
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Hao X, Li G, Ren J, Li J, He C, Zhang HQ. Endovascular Patch Embolization for Blood Blister–Like Aneurysms in Dorsal Segment of Internal Carotid Artery. World Neurosurg 2018; 113:26-32. [DOI: 10.1016/j.wneu.2018.01.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/01/2018] [Accepted: 01/04/2018] [Indexed: 11/16/2022]
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28
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Xu D, Zhang C, Wang T, Wang C, Kallmes DF, Lanzino G, You C, Xie X. Evaluation of Enterprise Stent-Assisted Coiling and Telescoping Stent Technique as Treatment of Supraclinoid Blister Aneurysms of the Internal Carotid Artery. World Neurosurg 2017; 110:e890-e896. [PMID: 29191548 DOI: 10.1016/j.wneu.2017.11.119] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 11/19/2017] [Accepted: 11/22/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Supraclinoid blister aneurysms (BAs) of the internal carotid artery are uncommon and deadly, and appropriate treatment is controversial. Endovascular reconstruction may allow treatment through aneurysm isolation. We report a single-institution experience in the use of Enterprise stent-assisted coiling (ESAC) for treating BAs to appraise the safety and efficacy of this technique. METHODS Patients treated with ESAC for a BA at our institution between 2013 and 2016 were retrospectively included in this study. Patients' aneurysm characteristics, progression status, aneurysm occlusion on follow-up angiography, and modified Rankin Scale (mRS) score were recorded and analyzed. Occlusion rates and neurologic outcomes were compared between patients treated with a single stent and those treated with multiple telescoping stents. RESULTS Forty-four patients were included (17 males; average age, 47.3 years), and ESAC was successfully performed in all patients. Immediate postprocedure angiography revealed complete occlusion in 23 patients (52.3%), residual neck in 15 (34.1%), and residual aneurysm in 6 (13.6%). Twenty patients (45.5%) suffered perioperative cerebral vasospasm, and 3 (6.8%) died of secondary ischemic stroke. The duration of follow-up ranged from 2.5 to 27 months (mean, 11.59 ± 5.76 months). One patient with recurrence was treated with additional coiling, and another patient was treated with a covered stent. The use of telescoping stents was associated with a better complete aneurysm occlusion rate compared with the use of single stents (84.4% [27 of 34] vs. 44.4% [4 of 9]; P = 0.04). Follow-up mRS score was ≤1 for 32 of 41 patients (78.4%). CONCLUSIONS ESAC to treat BAs is safe, effective, and provides good clinical outcomes. ESAC with telescoping stents has a higher follow-up complete occlusion rate compared with ESAC with single stents.
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Affiliation(s)
- Ding Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China; Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ting Wang
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chaohua Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaodong Xie
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
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Outcome After Subarachnoid Hemorrhage from Blood Blister–Like Aneurysm Rupture Depends on Age and Aneurysm Morphology. World Neurosurg 2017; 105:944-951.e1. [DOI: 10.1016/j.wneu.2017.06.129] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 11/20/2022]
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Overlapped Stenting Combined with Coiling for Blood Blister-Like Aneurysms: Comparison of Low-Profile Visualized Intraluminal Support (LVIS) Stent and Non-LVIS Stent. World Neurosurg 2017; 104:729-735. [DOI: 10.1016/j.wneu.2017.03.092] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/18/2017] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
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Shah SS, Gersey ZC, Nuh M, Ghonim HT, Elhammady MS, Peterson EC. Microsurgical versus endovascular interventions for blood-blister aneurysms of the internal carotid artery: systematic review of literature and meta-analysis on safety and efficacy. J Neurosurg 2017; 127:1361-1373. [PMID: 28298019 DOI: 10.3171/2016.9.jns161526] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) have a poor natural history associated with high morbidity and mortality. Currently, both surgical and endovascular techniques are employed to treat BBAs; thus, the authors sought to perform a meta-analysis to compare the efficacy and safety of these approaches. METHODS A literature search of PubMed, MEDLINE, and Google Scholar online databases was performed to include pertinent English-language studies from 2005 to 2015 that discussed the efficacy and safety of either surgical or endovascular therapies to treat BBAs. RESULTS Thirty-six papers describing 256 patients with BBAs treated endovascularly (122 procedures) or surgically (139 procedures) were examined for data related to therapeutic efficacy and safety. Pooled analysis of 9 papers demonstrated immediate and late (mean 20.9 months) aneurysm occlusion rates of 88.9% (95% CI 77.6%-94.8%) and 88.4% (95% CI 76.7%-94.6%), respectively, in surgically treated patients. Pooled analysis of 12 papers revealed immediate and late aneurysm obliteration rates of 63.9% (95% CI 52.3%-74.1%) and 75.9% (95% CI 65.9%-83.7%), respectively, in endovascularly treated aneurysms. Procedure-related complications and overall poor neurological outcomes were slightly greater in the surgically treated cases than in the endovascularly treated cases (27.8% [95% CI 19.6%-37.8%] vs 26.2% [95% CI 18.4%-35.8%]), indicating that endovascular therapy may provide better outcomes. CONCLUSIONS Blood-blister aneurysms are rare, challenging lesions with a poor prognosis. Although surgical management potentially offers superior aneurysm obliteration rates immediately after treatment and at the long-term follow-up, endovascular therapy may have a better safety profile and provide better functional outcomes than surgery. A registry of patients treated for BBAs may be warranted to better document the natural course of the disease as well as treatment outcomes.
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Stent Graft-in-Stent Graft as a Rescue Technique for Endovascular Treatment of Giant Extracranial Internal Carotid Aneurysm. Case Rep Surg 2016; 2016:2656421. [PMID: 27752387 PMCID: PMC5056233 DOI: 10.1155/2016/2656421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/02/2016] [Accepted: 09/05/2016] [Indexed: 11/17/2022] Open
Abstract
Endovascular treatment of a giant extracranial internal carotid aneurysm by a stent graft implantation was unsuccessful due to a high flow leak directly through the stent graft's coating. The problem was solved deploying a second stent graft inside the previously implanted one resulting in complete exclusion of the aneurysmal sac and patent carotid lumen preservation. The review of the literature did not provide a case using this endovascular strategy. Follow-up for more than 12 months, using CT angiography, showed confirmed aneurysmal exclusion and carotid patency and no clinical complications have been detected.
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Fang C, Tan HQ, Han HJ, Feng H, Xu JC, Yan S, Nie ZY, Jin LJ, Teng F. Endovascular isolation of intracranial blood blister-like aneurysms with Willis covered stent. J Neurointerv Surg 2016; 9:963-968. [DOI: 10.1136/neurintsurg-2016-012662] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/16/2016] [Accepted: 09/19/2016] [Indexed: 11/04/2022]
Abstract
ObjectiveIntracranial blood blister-like aneurysm (BBA) is a rare type of aneurysm that lacks all layers of the arterial wall. These fragile aneurysms have the propensity to rupture with minimal manipulation, which makes them hazardous and difficult to treat. The present study evaluated the safety and feasibility of endovascular treatment of BBAs with the Willis covered stent.MaterialsThirteen patients (7 men and 6 women, age range 28–68 years) who presented with ruptured BBAs and were treated with the Willis covered stent were retrospectively reviewed. Results of the procedures and treatment-related complications were recorded. Angiographic and clinical follow-ups were performed 4–6 months after the procedure.ResultsPlacement of the covered stent was successful in all patients. Immediate angiography showed complete aneurysm occlusion in 12 patients while one patient showed a mild endoleak. This high rate of aneurysm exclusion ensured the security of postoperative antiplatelet treatment. Occlusion of the ophthalmic artery occurred in two patients and occlusion of the anterior choroidal artery occurred in one patient; however, none of them showed acute or delayed clinical symptoms. Thrombosis, aneurysm rupture, and other complications did not develop in any case. Angiographic follow-up showed complete aneurysm exclusion without aneurysm recurrence in any patients. Only two patients showed asymptomatic mild to moderate in-stent stenosis. All patients had satisfactory clinical outcomes (modified Rankin Scale score ≤1).ConclusionsWillis covered stent implementation may be safe and feasible for BBAs. This strategy might be a promising option for this high-risk type of aneurysm.
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Linfante I, Mayich M, Sonig A, Fujimoto J, Siddiqui A, Dabus G. Flow diversion with Pipeline Embolic Device as treatment of subarachnoid hemorrhage secondary to blister aneurysms: dual-center experience and review of the literature. J Neurointerv Surg 2016; 9:29-33. [DOI: 10.1136/neurintsurg-2016-012287] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/11/2016] [Accepted: 03/18/2016] [Indexed: 11/03/2022]
Abstract
BackgroundAneurysmal subarachnoid hemorrhage (aSAH) secondary to blister-type aneurysms (BAs) is associated with high morbidity and mortality. Microsurgical clipping or wrapping and/or use of traditional endovascular techniques to repair the lesion result in frequent regrowth and rebleeds and ultimately high fatality rates. Because of the purely endoluminal nature of arterial reconstruction, flow diversion may represent an ideal option to repair ruptured BAs.MethodsWe performed a retrospective analysis of our database including all consecutive patients with aSAH secondary to BAs treated with the Pipeline Embolic Device (PED) between November 2013 and November 2015 in two institutions. We collected basic patient demographics, aneurysm size, location, number and sizes of PEDs used, use of coiling, 30-day modified Rankin Scale (mRS) score, and follow-up imaging data.ResultsTen cases of aSAH were found as a result of a ruptured BA. Patients had a mean age of 47.2 years (range 27–68). Mean Hunt and Hess score was 1.6 (range 1–4). Lesions were predominantly left-sided, mostly along the dorsal aspect of the internal carotid artery, either paraclinoid or paraophthalmic (8/10). In two patients the BA was located in the left middle cerebral artery. All lesions were very small (mean 1.4×1.5 mm; range 0.75–2.1 mm). Placement of a single PED resulted in immediate occlusion or near-occlusion of the BA in 9 out of 10 patients. Nine patients did very well; eight had a 90-day mRS score of 0 and one had a 90-day mRS score of 1. Follow-up digital subtraction angiography was performed in all patients (mean 15 months; range 7–24). In the surviving nine patients there was complete occlusion of the BA on long-term follow-up angiography.ConclusionsRepair of ruptured BA with PED may be a safe and durable option.
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Endovascular treatment of ruptured blood blister-like aneurysms with multiple (≥3) overlapping Enterprise stents and coiling. Acta Neurochir (Wien) 2016; 158:803-809. [PMID: 26858206 DOI: 10.1007/s00701-016-2721-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Blood blister-like aneurysms (BBAs) are difficult to treat both surgically and endovascularly, and the optimal treatment remains controversial. The aim of this study was to evaluate the clinical and angiographic feasibility of multiple overlapping stents (≥3) with coiling for treating BBA. METHODS A retrospective review from four institutions identified ten patients with ruptured BBAs who were treated with multiple overlapping stents (≥3). We included both the patients who were initially treated with more than three stents and those who eventually had more than three stents as a consequence of retreatment. Angiographic results (Raymond scale), clinical outcomes (mRS) and treatment courses were evaluated. RESULTS Initially, seven patients were treated with triple stents and three with double stents. Immediate angiographic results revealed that six aneurysms were Raymond grade 1, three were grade 2, and one was grade 3. Complementary treatment was required in four patients. All three patients who were initially treated with double stents required complementary treatment (100 %). One patient required complementary treatment among the seven patients who were initially treated with three stents (14.3 %). The last follow-up angiography (mean, 12.2 ± 14.7 months; range, 1-44 months) revealed grade 1 in all ten patients. Clinical data (mean follow-up period, 18.2 ± 20.1 months; range, 1-62 months) revealed eight patients with a mRS score of 0-2 and two with mRS 3-5. CONCLUSIONS Even in the era of flow diverter stents, multiple overlapping stents (≥3) with coiling could be a feasible alternative for treating ruptured BBAs. Additional experience and follow-up are needed in a larger series to state the long-term efficacy of this treatment.
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Rouchaud A, Brinjikji W, Cloft HJ, Kallmes DF. Endovascular Treatment of Ruptured Blister-Like Aneurysms: A Systematic Review and Meta-Analysis with Focus on Deconstructive versus Reconstructive and Flow-Diverter Treatments. AJNR Am J Neuroradiol 2015; 36:2331-9. [PMID: 26381557 DOI: 10.3174/ajnr.a4438] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/09/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Various endovascular techniques have been applied to treat blister-like aneurysms. We performed a systematic review to evaluate endovascular treatment for ruptured blister-like aneurysms. MATERIALS AND METHODS We performed a comprehensive literature search and subgroup analyses to compare deconstructive versus reconstructive techniques and flow diversion versus other reconstructive options. RESULTS Thirty-one studies with 265 procedures for ruptured blister-like aneurysms were included. Endovascular treatment was associated with a 72.8% (95% CI, 64.2%-81.5%) mid- to long-term occlusion rate and a 19.3% (95% CI, 13.6%-25.1%) retreatment rate. Mid- to long-term neurologic outcome was good in 76.2% (95% CI, 68.9%-8.4%) of patients. Two hundred forty procedures (90.6%) were reconstructive techniques (coiling, stent-assisted coiling, overlapped stent placement, flow diversion) and 25 treatments (9.4%) were deconstructive. Deconstructive techniques had higher rates of initial complete occlusion than reconstructive techniques (77.3% versus 33.0%, P = .0003) but a higher risk for perioperative stroke (29.1% versus 5.0%, P = .04). There was no difference in good mid- to long-term neurologic outcome between groups, with 76.2% for the reconstructive group versus 79.9% for the deconstructive group (P = .30). Of 240 reconstructive procedures, 62 (25.8%) involved flow-diverter stents, with higher rates of mid- to long-term complete occlusion than other reconstructive techniques (90.8% versus 67.9%, P = .03) and a lower rate of retreatment (6.6% versus 30.7%, P < .0001). CONCLUSIONS Endovascular treatment of ruptured blister-like aneurysms is associated with high rates of complete occlusion and good mid- to long-term neurologic outcomes in most patients. Deconstructive techniques are associated with higher occlusion rates but a higher risk of perioperative ischemic stroke. In the reconstructive group, flow diversion carries a higher level of complete occlusion and similar clinical outcomes.
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Affiliation(s)
- A Rouchaud
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota.
| | - W Brinjikji
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - H J Cloft
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - D F Kallmes
- From the Department of Radiology, Mayo Clinic, Rochester, Minnesota
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Rouchaud A, Brinjikji W, Cloft H, Kallmes D. Endovascular Treatment of Ruptured Blister-Like Aneurysms: A Systematic Review and Meta-Analysis with Focus on Deconstructive versus Reconstructive and Flow-Diverter Treatments. AJNR Am J Neuroradiol 2015. [DOI: 10.3174/ajnr.a4438 [doi].] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Szmuda T, Sloniewski P, Waszak PM, Springer J, Szmuda M. Towards a new treatment paradigm for ruptured blood blister-like aneurysms of the internal carotid artery? A rapid systematic review. J Neurointerv Surg 2015; 8:488-94. [PMID: 25792038 DOI: 10.1136/neurintsurg-2015-011665] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/02/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE Owing to their peculiar features and rare occurrence, ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery are challenging by both surgical and endovascular approaches and their proper management is uncertain. We therefore aimed to define the currently optimal treatment of ruptured BBAs in terms of mortality, outcome, rebleeding, and recurrence. METHOD An in-depth search of electronic databases, gray literature and internet resources for ruptured BBAs was performed and complemented by data retrieval during neurosurgical congresses. Clinical and radiological characteristics, intervention details, outcomes, and the impact factor of the source journal were pooled. RESULTS The pooled cohort comprised 311 patients. Neither surgical nor endovascular methods had an impact on clinical outcome, aneurysm regrowth, remote bleeding, or complication rate. By contrast, aneurysm clipping was a predictor of intraoperative bleeding (OR 6.5; 95% CI 1.2 to 34.3), and stent-assisted coiling increased the likelihood of a second treatment (OR 4.1; 95% CI 1.3 to 13.1), its conversion to another modality (OR 4.7; 95% CI 1.4 to 16.0), and incomplete aneurysm obliteration (OR 2.6; 95% CI 1.0 to 6.6). Higher impact journals were more likely to publish papers on endovascular techniques, particularly flow-diverter stents. CONCLUSIONS None of the methods is unequivocally superior. Considering its inefficiency, stent-assisted coiling should be undertaken with caution. A time-delimited systematic review is needed to establish the most accurate treatment for ruptured BBAs.
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Affiliation(s)
- Tomasz Szmuda
- Neurosurgery Department, Medical University of Gdansk, Gdansk, Poland
| | - Pawel Sloniewski
- Neurosurgery Department, Medical University of Gdansk, Gdansk, Poland
| | - Przemyslaw M Waszak
- Students Scientific Association at Neurosurgery Department, Medical University of Gdansk, Gdansk, Poland
| | - Janusz Springer
- Department of Preventive Medicine and Education, Medical University of Gdansk, Gdansk, Poland
| | - Marta Szmuda
- Developmental Neurology, Medical University of Gdansk, Gdansk, Poland
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Ashour R, Dodson S, Aziz-Sultan MA. Endovascular management of intracranial blister aneurysms: spectrum and limitations of contemporary techniques. J Neurointerv Surg 2014; 8:30-7. [DOI: 10.1136/neurintsurg-2014-011443] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/20/2014] [Indexed: 11/03/2022]
Abstract
BackgroundIntracranial blister aneurysms are rare lesions that are notoriously more difficult to treat than typical saccular aneurysms. High complication rates associated with surgery have sparked considerable interest in endovascular techniques, though not well-studied, to treat blister aneurysms.ObjectiveTo evaluate our experience using various endovascular approaches to treat blister aneurysms.MethodsAll consecutive blister aneurysms treated using an endovascular approach by the study authors over a 3-year period were retrospectively analyzed. A literature review was also performed.ResultsNine patients with blister aneurysms underwent 11 endovascular interventions. In various combinations, stents were used in 8/11, coils in 5/11, and Onyx in 3/11 procedures. At mean angiographic follow-up of 200 days, 8/9 aneurysms were completely occluded by endovascular means alone requiring no further treatment and 1/9 aneurysms required surgical bypass/trapping after one failed surgical and two failed endovascular treatments. At mean clinical follow-up of 416 days, modified Rankin Scale scores were improved in six patients, stable in two, and worsened in one patient. One complication occurred in 11 procedures (9%), resulting in a permanent neurologic deficit. No unintended endovascular parent vessel sacrifice, intraprocedural aneurysmal ruptures, antiplatelet-related complications, post-treatment aneurysmal re-ruptures, or deaths occurred.ConclusionThis series highlights both the spectrum and limitations of endovascular techniques currently used to treat blister aneurysms, including a novel application of stent-assisted Onyx embolization. Long-term follow-up and experience in larger studies are required to better define the role of endovascular therapy in the management of these difficult lesions.
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Endovascular approaches for blister aneurysms of the internal carotid artery: Conventional stents versus flow diverters. Clin Neurol Neurosurg 2014; 126:210. [DOI: 10.1016/j.clineuro.2014.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/03/2014] [Indexed: 11/20/2022]
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