Endovascular Patch Embolization for Blood Blister–Like Aneurysms in Dorsal Segment of Internal Carotid Artery

Treatment with a flow diverter-assisted coil embolization for ruptured blood blister-like aneurysms of the internal carotid artery: a technical note and analysis of single-center experience with pooled data

Treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) with flow diverters (FDs) has become widespread in recent years. However, ruptured blood blister-like aneurysm (BBA) of ICA treatment with flow diverter-assisted coil embolization (FDAC) remains controversial. Moreover, limited direct comparative studies have been conducted between the two treatment modalities, FDs and FDAC, for BBAs. The purpose of this study was to document our experience and evaluate the effectiveness and safety of FDAC. We conducted a retrospective analysis of clinical and radiological information from ten patients who experienced ruptured BBAs of the supraclinoid ICA at our center from January 2021 to February 2023. The technical details of FDAC for ruptured BBAs were described, and the technical steps were named "pipeline embolization device (PED)-Individualized shaping(microcatheter)-Semi deploying-Rivet(coils)-Massage(microwire)" as the PEISSERM technique. Clinical outcomes were assessed using the modified Rankin Scale (mRS), whereas radiological results were determined through angiography. A pooled analysis was implemented, incorporating data from literature sources that reported perioperative and long-term clinical and angiographic outcomes of ruptured BBAs treated with FD and FDAC strategies, along with our data. Data in our analysis pool were categorized into FD and FDAC strategy groups to explore the preferred treatment modalities for BBAs. The PEISSERM technique was utilized to treat ten patients, seven males, and three females, with an average age of 41.7 years. A single PED was deployed in conjunction with coils in all ten patients. All PEDs were documented to have good wall apposition. The immediate postoperative angiograms demonstrated Raymond grade I in ten aneurysms. Angiographic follow-up of nine patients at 4-25 months showed total occlusion of the aneurysms. At the most recent follow-up, the mRS scores of nine patients hinted at a good prognosis. Pooled analysis of 233 ICA-BBA cases of FD revealed a technical success rate of 91% [95% confidence interval (CI), 0.88 to 0.95], a rate of complete occlusion of 79% (95% CI, 0.73 to 0.84), a recurrence rate of 2% (95% CI, 0.00 to 0.04), a rebleed rate of 2% (95% CI, 0.00 to 0.04), and the perioperative stroke rate was 8% (95% CI, 0.04 to 0.11). The perioperative mortality was 4% (95% CI, 0.01 to 0.07). The long-term good clinical outcome rate was 85% (95% CI, 0.80 to 0.90). The mortality rate was 6% (95% CI, 0.03 to 0.09). Results from the subgroup analysis illustrated that the FDAC strategy for BBAs had a significantly higher immediate postoperative complete occlusion rate (P < 0.001), total occlusion rate (P = 0.016), and a good outcome rate (P = 0.041) compared with the FD strategy. The FDAC strategy can yield a higher rate of good outcomes than the FD strategy. The PEISSERM technique employed by the FDAC is a reliable and effective treatment approach as it can minimize the hemodynamic burden of BBA's fragile dome, thereby achieving an excellent occlusion rate. The PEISSERM technique in the FDAC strategy contributes to understanding the BBA's treatment and offers a potentially optimal treatment for BBA.

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.

Treatment of Traumatic Internal Carotid Artery Aneurysm by Flow-Diverter: A Single-Center Experience

AIM

Traumatic intracranial aneurysm (TICA) is a rare vascular lesion with various etiologies and a high mortality rate when diagnosed late. In this study, we present our cases of TICA, which we treated with flow-diverter stents due to different etiological factors.

METHODS

Clinical data were recorded for 8 patients: age, gender, etiological factors, aneurysm location, aneurysm type, rupture, main artery status, and postoperative complications.

RESULTS

75% (n:6) of the patients were male and 25% (n:2) female. Etiologically, there was intracranial tumor surgery in 3 cases (37.5%), fall from height in 2 (25%), road accident in 2 (25%), and blunt trauma in 1 (12.5%). Reconstruction used a flow-diverting stent in all cases. One patient experienced intraoperative iatrogenic rupture of the distal arterioles due to a microwire. Mean angiographic follow-up was 17.8 months (range, 6-32 months). During follow-up, none of the patients required renewed endovascular treatment.

CONCLUSION

Traumatic aneurysm is a vascular lesion with high mortality when diagnosed late. In case of suspected vascular injury after trauma or intracranial surgery, further evaluation should be performed without delay. TICA can be safely treated with flow-diverter stents, conserving the main artery.

Treatment of Blood Blister Aneurysms of the Internal Carotid Artery With Pipeline-Assisted Coil Embolization: A Single-Center Experience

Background

Blood blister aneurysm (BBA) is a complex and rare aneurysm that presents significant treatment challenges. The application of pipeline embolization device (PED)-assisted coiling in the treatment of ruptured BBA remains controversial. This study aimed to report on our experience and assess the safety and efficacy of this strategy.

Methods

Between February 2019 and February 2021, 12 patients with ruptured BBAs underwent PED-assisted coil embolization. We collected detailed data about each patient, including demographic information, aneurysmal data, technical details, antiplatelet strategy, operation-related complications, and follow-up outcomes.

Results

A total of 12 BBA patients were treated with single PED-assisted coil embolization. One patient experienced intraoperative rupture that was controlled by rapid coiling without clinical consequences. All the patients demonstrated complete occlusion on postoperative angiography. A total of three patients had postoperative complications: left hemiparesis, Broca's aphasia, and right hemiplegia due to vasospasm, and transient hemiparesis. Follow-up angiography revealed that all BBAs were completely occluded, except one with neck residue. All patients had favorable outcomes at discharge and the most recent clinical follow-up (mRS score ≤ 2).

Conclusion

Endovascular treatment of BBAs of the internal carotid artery using PED-assisted coil embolization is a safe and effective strategy. This has contributed to the understanding of BBA therapy and provides a potentially optimal treatment option for this intractable lesion.

Wrap-Clipping for Patients with Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery: Case Series and Literature Review

OBJECTIVE

 Blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) are challenging to treat. We assessed the clinical and radiologic outcomes in patients with ruptured BBAs of the ICA treated with wrap-clipping.

METHODS

 From November 2016 to January 2020, the clinical and radiologic data of patients with subarachnoid hemorrhage (SAH) caused by ICA BBAs who underwent wrap-clipping were retrospectively analyzed. The clinical outcomes were evaluated according to the modified Rankin Scale (mRS). Radiologic follow-up examinations included digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA).

RESULTS

 Seven patients were enrolled in this study. All BBAs were wrap-clipped successfully, including two BBAs that exhibited intraoperative bleeding and required balloon-assistance during surgery. All patients had favorable clinical outcomes during follow-up. Among the six patients who completed the radiologic follow-up visit, one patient presented ICA occlusion at the 6-month DSA follow-up, but no neurologic dysfunction was noted. We did not observe the progression of ICA stenosis in other patients.

CONCLUSION

 All BBAs in this study were wrap-clipped successfully and completely occluded. Wrap-clipping is effective for BBAs of the ICA and has favorable clinical outcomes. A multicenter study with a large sample size and a longer radiologic follow-up is necessary.

Comparison of Blister Aneurysm Treatment Techniques: A Systematic Review and Meta-Analysis

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.

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

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.

Flow Diverter-Assisted Coil Embolization of Blood Blister-Like Aneurysm Using Semi-deploying Technique

Despite many therapeutic methods were utilized to treat blood blister-like aneurysms (BBAs), the optimal treatment approach has not yet been defined. This study presents the single center experience with BBAs treated with flow diverter-assisted coiling using semi-deploying technique, and discusses the efficacy and safety of the method. The patients with subarachnoid hemorrhages (SAH) due to BBAs and treated with Pipeline Flex Embolization Device (PED) between November 2015 and February 2019 in our hospital were retrospectively reviewed. Patient demographic data, timing of treatment, angiographic details, treatment techniques, clinical outcomes and follow-up results were recorded. Ten cases (6 women and 4 men) were enrolled. The mean age of patients was 50.7 years (range 40–61 years). The aneurysm size ranged from 2 × 1.7 mm to 4.5 × 3.8 mm. Seven patients were treated with PED assisted coil embolization using semi-deploying technique, and all of the aneurysms were totally obliterated at the follow up. One patient treated with PED assisted coil embolization suffered from parenchymal hemorrhage 3 days after the treatment, and another one patient also treated with PED and coil died of severe vasospasm 10 days after the treatment. There was no reruptured cases during the follow-up. Here we showed that PED assisted coil embolization using semi-deploying technique could be a technically safe and effective treatment for BBAs.

Current Knowledge of and Perspectives about the Pathogenesis of Blood Blister-like Aneurysms of the Internal Carotid Artery: A Review of the Literature

Blood blister-like aneurysms (BBAs) are rare and usually appear at nonbranching sites in the supraclinoid portion of the internal carotid artery (ICA). Because it is difficult to obtain histological specimens of the aneurysm wall and because experimental models are challenging to establish, the pathogenesis of BBAs remains uncertain. In this paper, we reviewed the diagnostic, radiological, and pathophysiological characteristics of patients with BBAs. We also summarized the existing evidence and potential mechanisms related to the causes of BBAs. Current evidence indicates that atherosclerosis and dissection are the main prerequisites for the formation of BBAs. Hemodynamics may play a role in the process of BBA formation due to the unique vascular anatomy of the supraclinoid ICA. Further research on histopathology and hemodynamics is warranted in this field.

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.

Endovascular Trapping for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: A Case Report and Review of the Literature

Objective

Rupture of blood blister-like aneurysm (BBA) of the internal carotid artery (ICA) may result in fatal subarachnoid hemorrhage (SAH). Open surgery including bypass surgery has been performed to treat the aneurysm. Recently, endovascular treatment is developing for the treatment of cerebral aneurysm. Here, we report a case of ruptured BBA of the ICA, treated by endovascular trapping and review the literatures.

Case Presentation

A 37-year-old woman was brought to our hospital to treat SAH. Computed tomography (CT) angiography showed no apparent cause of the hemorrhage except for the minor dilation of the C2 portion of the left ICA. After 3 days, the CT angiography demonstrated progression of the dilation with the formation of a bleb. Evaluating collateral circulation through anterior communicating artery, endovascular trapping of the ICA was performed. Although she suffered minor ischemic stroke postoperatively, the symptoms recovered completely and discharged without neurological deficit.

Review of Literatures

we reviewed the 11 cases of ruptured BBA treated by endovascular trapping. The results of ICA occlusion based on the evaluation of collateral circulation were satisfactory because rebleeding as well as regrowth of the aneurysm were prevented. However, hemodynamic compromise and treatment for vasospasm following SAH are considered.

Conclusion

Rebleeding from BBA of the ICA should be prevented first and ischemic complication is avoided secondary. Endovascular trapping following evaluation of the collateral circulation is definitive treatment of BBA of the ICA.

Endovascular Intervention with a Low-profile Visualized Intraluminal Support Stent Versus Surgical Clipping for Blood Blister-like Aneurysms : A Retrospective Study

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.

Treatment of traumatic intracranial aneurysm: Experiences at a single center

OBJECTIVE

To report the treatment and outcome of traumatic intracranial aneurysm (TICA) cases at the Southwest Hospital, Army Medical University in China.

PATIENTS AND METHODS

All patients diagnosed with TICA at our institution from January 1, 1977, to October 31, 2018, and meeting the inclusion/exclusion criteria were included in the study. Cases were reported separately for those diagnosed before 1998 and those after 1998.

RESULTS

A total of 25 patients were included in the study. Ten were diagnosed with TICA prior to 1998. Seven of these 10 patients were treated surgically with parent artery sacrificed, including aneurysmectomy, trapping, and bypass. The mean Glasgow Outcome Scale (GOS) score for the 7 patients with surgical treatment was 3.1. Three of the 10 patients died of severe complications, including intracranial infection, delayed bleeding, and deadly injury. After 1998, 15 patients were diagnosed with TICA. Thirteen presented with head trauma and two with iatrogenic TICA following ventricle drainage or sphenoid ridge meningioma resection. Thirteen were treated with endovascular treatment, including coil alone, glue, coil-associated glue, stent alone, stent-assisted coil embolization, one with clipping, and one with conservative treatment. The 13 patients with endovascular treatment achieved a mean GOS score of 4.5. Among the 13 patients, one died from intracranial infection, one suffered recurrence, and one had intraoperative rupture.

CONCLUSION

Although the treatment of TICA has traditionally been surgical, endovascular treatment with different techniques, such as endovascular patch, provides a valuable alternative. Currently, the flow diverter is a popular embolization device and may represent another valid treatment option for TICA.