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Panni P, Riccio L, Cao R, Pedicelli A, Marchese E, Caricato A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Lanterna AL, Ambrosi A, Mortini P, Beretta L, Falini A. Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry. Neurosurgery 2023; 93:636-645. [PMID: 37010298 DOI: 10.1227/neu.0000000000002467] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVES To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. METHODS Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. RESULTS Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). CONCLUSION UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.
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Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia Riccio
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Cao
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Pedicelli
- Institute of Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care Medicine Fondazione Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Alberto Feletti
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mattia Testa
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Zanatta
- Anesthesia and Intensive Care A, Integrated University Hospital, Verona, Italy
| | - Nicola Gitti
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Dikran Mardighian
- Department of Neuroradiology Spedali Civili University Hospital, Brescia, Italy
| | | | - Giordano Nardin
- Department of Critical Care, SS Annunziata Hospital, Taranto, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito-Fazzi Hospital, Lecce, Italy
| | - Giafranco Paiano
- Department of Anaesthesia and Critical Care, Vito-Fazzi Hospital, Lecce, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Carlo Bortolotti
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Antonino Scibilia
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Luigi Cirillo
- Department of Neuroradiology, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | | | | | - Pietro Mortini
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Beretta
- Department of Neurocritical Care San Raffaele University Hospital, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Binh NT, Duc NM, Tuyen LV, My TTT, Linh LT. Endovascular treatment of ruptured blister-like aneurysms: A case report and review of the literature. Radiol Case Rep 2021; 16:3790-3793. [PMID: 34646410 PMCID: PMC8501687 DOI: 10.1016/j.radcr.2021.09.018] [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: 08/25/2021] [Accepted: 09/08/2021] [Indexed: 11/25/2022] Open
Abstract
A ruptured blister-like aneurysm of the internal carotid artery is a rare event with a high risk of recurrence and mortality. Selecting an appropriate treatment modality remains challenging due to a lack of consensus or specific recommendations in the literature. In this article, we present the case of a 68-year-old man who presented with ruptured blister-like aneurysms in the supraclinoid portion of the internal carotid artery. The patient was diagnosed and successfully managed using an endovascular coil embolization technique at our hospital. We aim to illustrate and share our experiences with this rare occurrence, which may assist in the treatment of similar cases in the future.
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Affiliation(s)
- Nguyen Thai Binh
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam
- Department of Radiology, Children's Hospital 2, Ho Chi Minh City, Viet Nam
- Corresponding author.
| | - Le-Van Tuyen
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Thieu-Thi Tra My
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Le Tuan Linh
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
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Zhang J, Yu M, Lv X. Endovascular treatment of blood blister-like aneurysms of internal carotid artery: Stent-assisted coiling and pipeline flow diversion. J Clin Neurosci 2021; 90:8-13. [PMID: 34275585 DOI: 10.1016/j.jocn.2021.04.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/25/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To report the stent-assisted coil embolization and flow diversion treatments of blood-blister-like aneurysms based on the theory of acute dissection of the internal carotid artery. PATIENTS AND METHODS From July 2016 through July 2020, 27 patients presenting with subarachnoid hemorrhage (SAH) due to rupture of internal carotid artery blood blister-like aneurysms were subjected to endovascular treatment with stent-assisted coiling or Pipeline flow diversion. Clinical outcomes were evaluated using modified Rankin Scale score (mRS). RESULTS A proximal stenosis caused by angiopathology adjacent to aneurysms were found on internal carotid artery angiograms in all 27 cases. The angiopathology combining with the aneurysms implement that acute dissection of the supraclinoid segment of the internal carotid artery indicated the pathogenesis of blood blister-like aneurysm formation. All aneurysms were treated successfully with alleviation of the adjacent angiopathology after stenting on angiograms. During 1-12 months, mean 3.5 months, complete aneurysm obliteration without adjacent stenosis were found in 25(92.6%) patients. Two (7.4%) cases of recanalization were retreated with complete obliteration at 1 week and 3 months after initial treatment. Clinical mRS 0 and 1 outcomes were observed in 23(85.2%) patients, mRS 2 in 3(11.1%) patients and mRS 6 in 1(3.7%) not related to aneurysm treatment during follow-up. CONCLUSIONS Acute focal dissection of supraclinoid segment of internal carotid artery underlies the development of blood blister-like aneurysm. Stent-assisted coiling and flow diversion treatments constitute appropriate treatment based on the arterial dissection pathology.
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Affiliation(s)
- Jiwei Zhang
- Neurosurgery Department, Affiliated Hospital of Chengde Medical College, Chengde, Hebei, China
| | - Miao Yu
- Neurosurgery Department, Affiliated Hospital of Chengde Medical College, Chengde, Hebei, China
| | - Xianli Lv
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
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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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Ye Z, Lv X. The formation mechanism of acute dissection of blood blister-like aneurysm and its implication of endovascular treatment. Chin Neurosurg J 2021; 7:32. [PMID: 34078466 PMCID: PMC8173849 DOI: 10.1186/s41016-021-00245-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 04/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute mural dissection of the anterior wall of the internal carotid artery which may contribute to the development of blood blister-like aneurysms (BBLAs) was postulated, and stenting or flow diversion treatment across the soi-disant aneurysm was reported in this study. METHODS From December 2016 to December 2018, 8 patients presenting with subarachnoid hemorrhage (SAH) due to BBLA were subjected to endovascular treatment with stent-assisted coiling. Clinical outcomes were evaluated using a clinical outcome score scale. RESULTS Based on angiograms, pathologic change involving the supraclinoid segments of the internal carotid artery (ICA) adjacent to BBLA was found in all patients. This pathologic change meant a focal dissection of the supraclinoid segment of the ICA which constituted the pathogenesis of BBLAs. Closed-cell, open-cell, and braided stents were used in 1, 1, and 6 patients, respectively. Complete obliteration was achieved following endovascular treatment among all 8 patients harboring BBLA. One re-bleeding successive to a closed-cell stent across the aneurysmal neck was observed. Follow-up angiograms revealed stable complete exclusion of all BBLAs from the parent vessel at 3 to 8 months. All patients had a favorable clinical outcome score of 0-1. CONCLUSIONS Acute dissection of a focal point of the intracranial vessels underlies the development of BBLAs. Open-cell and braided-cell stent-assisted coiling may constitute appropriate treatment due to good apposition against the vascular walls. Adjunctive coils may facilitate immediate complete occlusion of BBLAs.
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Affiliation(s)
- Zhongyin Ye
- School of Medicine& School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xianli Lv
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Litang Road 168, Beijing, 102218, China.
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Jung HN, Suh SI, Ryoo I, Kim I. Usefulness of 3D High-resolution Vessel Wall MRI in Diffuse Nonaneurysmal SAH Patients. Clin Neuroradiol 2021; 31:1071-1081. [PMID: 33974086 DOI: 10.1007/s00062-021-01018-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/11/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE In 15-20% of patients with nontraumatic diffuse subarachnoid hemorrhage (SAH), the initial conventional angiography does not reveal a causative vascular abnormality, such as intracranial aneurysm. In this study, we evaluated clinical utility of 3D high-resolution vessel wall magnetic resonance imaging (HR-VWI) in patients with diffuse nonaneurysmal SAH. METHODS A total of 17 patients with diffuse nonaneurysmal SAH were included in this retrospective study. We characterized demographics and HR-VWI findings and reviewed the clinical management and outcomes. RESULTS Of the patients 14 (14/17; 82.4%,) showed abnormal findings on HR-VWI, including 5 with intracranial dissections (29.4%), 3 with blood blister-like aneurysm (17.6%), 1 with ruptured fusiform aneurysm (5.9%), and 5 with focal nodular wall enhancement without unclassified pathology (29.4%). Of these patients were treated with endovascular management. Most patients (16/17) had a favorable modified Rankin scale scores of 0-2 on discharge. CONCLUSION The 3D HR-VWI revealed various hidden pathologies, such as intracranial arterial dissection, blood blister-like aneurysm, and fusiform aneurysm in patients with diffuse nonaneurysmal SAH. In addition, 3D HR-VWI had an impact on the management of SAH. The 3D HR-VWI can be a complementary diagnostic method for patients with diffuse nonaneurysmal SAH in a research or clinical setting.
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Affiliation(s)
- Hye Na Jung
- Department of Radiology, Guro Hospital, Korea University College of Medicine, 148 Guro-dong, 08308, Guro-gu, Seoul, Korea (Republic of)
| | - Sang-Il Suh
- Department of Radiology, Guro Hospital, Korea University College of Medicine, 148 Guro-dong, 08308, Guro-gu, Seoul, Korea (Republic of).
| | - Inseon Ryoo
- Department of Radiology, Guro Hospital, Korea University College of Medicine, 148 Guro-dong, 08308, Guro-gu, Seoul, Korea (Republic of)
| | - InSeong Kim
- Siemens Healthineers Ltd., Seoul, Korea (Republic of)
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Wen D, Chen R, Kieran NW, Sharifian-Dorche M, Liu W, Li H, You C, Yang M, Ma L. Comparison of clinical and histopathological characteristics of short-term progressive and non-progressive blood blister-like aneurysms. Acta Neurochir (Wien) 2021; 163:1167-1179. [PMID: 33427988 DOI: 10.1007/s00701-020-04697-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/28/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Many blood blister aneurysms (BBAs) have been documented with a rapid progression history in repeated angiography. The underlying mechanism and clinical significance remained elusive. This current study aims to clarify the clinical and histopathological differences between short-term progressive BBA and non-progressive BBAs. METHODS AND MATERIALS Eighty-one patients with BBAs were consecutively included for this single-center retrospective analysis. Clinical and radiological data on these patients were retrieved from 2017 to 2019. BBAs were defined as either progressive or non-progressive based on observed growth based on repeated imaging. Histopathological examinations of a saccular aneurysm, a progressive BBA, and a non-progressive BBA were conducted using representative aneurysm samples. RESULTS Among all enrolled patients, 26 of the them were identified with progressive BBAs, while the other 55 with non-progressive BBAs. Progressive BBAs were diagnosed significantly earlier in angiography (3.36 ± 0.61 vs. 6.53 ± 1.31 days, p < 0.05) and showed a higher presence rate of daughter sacs (61.5 vs. 38.2%, p < 0.05). Three different progression patterns were identified. BBAs that developed daughter sac enlargement are diagnosed significantly later than BBAs exhibiting other progression patterns. Patients with progressive and non-progressive BBAs exhibited similar overall clinical outcomes and incidence for complications. For patients with non-progressive BBAs, microsurgery appears to be inferior to endovascular treatment, while for patients with progressive BBAs, the short-term outcomes between microsurgery and endovascular treatment were identical. Histopathological analysis revealed that both subtypes shared a similar pseudoaneurysms structure, but non-progressive BBAs had more histologically destructed aneurysm wall with less remnant fibrillar collagen in adventitia. CONCLUSIONS Progressive and non-progressive BBAs may not be distinct pathological lesions but represent different stages during the BBA development. Early intervention, regardless of treatment methods, is recommended for salvageable patients with progressive BBAs, but microsurgery should be performed with caution for non-progressive BBAs due to increased surgical risk.
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Chen S, Chen X, Ning B, Cao Y, Wang S. Supraclinoid internal carotid artery blister-like aneurysms: hypothesized pathogenesis and microsurgical clipping outcomes. Chin Neurosurg J 2021; 7:10. [PMID: 33517915 PMCID: PMC7849078 DOI: 10.1186/s41016-020-00226-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blister-like aneurysms (BLAs) on the supraclinoid segment of the internal carotid artery (ICA) are an enigma of cerebrovascular disease. Neither has a definite pathogenesis been so far identified, nor have uniform treatment guidelines been established for them. Our aim was to develop a hypothesis regarding the evolution of BLAs according to their macroscopic morphologies and to evaluate the efficacy of microsurgical clipping. METHODS The clinical data and morphological features of 15 consecutive patients with 16 BLAs on the supraclinoid ICA were retrospectively reviewed. The treatment strategies were analyzed, and functional outcomes were evaluated using the modified Rankin scale (mRS). Favorable outcomes were defined as a mRS score of 0-2. RESULTS Morphologically, aneurysm growth with expansion of the aneurysm neck before the surgical procedure occurred in two ruptured and one unruptured aneurysm. Daughter bleb formation was observed in two ruptured and five unruptured aneurysms. A varied degree of parent artery sclerosis was observed in nine patients. Thirteen patients were treated with direct surgical clipping, one patient was treated with clipping and wrapping, and the remaining patient was treated with an encircling clipping graft. Favorable and unfavorable outcomes were observed in 13 and two cases, respectively. Follow-up angiograms revealed 4 cases of stenosis with respective degree of mild, 30%, 50%, and 80% without any neurological dysfunction. CONCLUSIONS We suggest a hypothesis that BLAs on the supraclinoid ICA may share different evolving mechanisms between ruptured and unruptured lesions. A majority of them can be reliably and safely obliterated by direct clipping technique, except for the aneurysms accompanied with severely atherosclerotic parent walls.
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Affiliation(s)
- Shanwen Chen
- Department of Neurosurgery, the Hospital of Shunyi District, No.3 Guangming Nan Street, Shunyi District, Beijing, 101300, China
| | - Xin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China
| | - Bo Ning
- Department of Neurosurgery, Guangzhou Red Cross Hospital, Jinan University, No. 396 Tongfu Zhong Road, Haizhu District, Guangzhou, 510220, Guangdong, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, No. 119 South 4th Ring West Road, Fengtai District, Beijing, 100050, China.
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Chen H, Chen R, Yang H, Li H, Wang J, Yu J. Outcome of a Blood Blister-Like Aneurysm Treated by Clip-Reinforced Wrapping Technique Using Y-Shaped Temporalis Fascia for Perforator Protection. World Neurosurg 2019; 128:376-380. [PMID: 30986585 DOI: 10.1016/j.wneu.2019.04.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal approach of blood blister-like aneurysms (BBAs) is debated. Wrapping has been reported to be an effective strategy, but artificial materials have often been used. In addition, perforator protection is difficult using this technique. In this case, we report a ruptured BBA of the left internal carotid artery (ICA) treated with a clip-reinforced wrapping technique using Y-shaped autologous temporalis fascia to protect the posterior communicating artery (PComA). The outcome was favorable. CASE DESCRIPTION A 48-year-old woman was admitted for subarachnoid hemorrhage. Digital subtraction angiography (DSA) revealed a BBA located opposite the PComA origin. A frontotemporal craniotomy was performed. The temporalis fascia was isolated from the temporalis muscle, and then tailored into a Y shape for the PComA to pass through. The diseased segment and the BBA were then wrapped by the Y-shaped temporalis fascia circumferentially. Two clips were applied to the fascia to reinforce the wrapping to fit snugly enough around the parent artery subsequently. DSA and computed tomography angiography scan postoperation showed that the BBA had not recurred, the supraclinoid segment of the left ICA had reconstructed well, and the PComA was unobstructed. The patient recovered without any sequelae during the 1-year follow-up period. CONCLUSIONS A clip-reinforced wrapping technique using Y-shaped temporalis fascia may be an effective method for treating BBAs located opposite the PComA origin. Long-term follow-up and large sample size studies, however, are necessary to validate this approach.
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Affiliation(s)
- Hao Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Rudong Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Hongkuan Yang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Hua Li
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Junhong Wang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China
| | - Jiasheng Yu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, P.R. China.
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Jiang Y, Li Y. Treatment of tiny intracranial aneurysms with guidewire manipulation. Chin Neurosurg J 2017. [DOI: 10.1186/s41016-017-0103-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Angiographic Appearance of Pulsatile Blister Aneurysm. World Neurosurg 2017; 110:371-372. [PMID: 29174231 DOI: 10.1016/j.wneu.2017.11.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/12/2017] [Accepted: 11/15/2017] [Indexed: 02/05/2023]
Abstract
A male with detected subarachnoid hemorrhage was admitted to our center. During the first angiography, a pulsatile blister aneurysm was revealed and the aneurysm was also noticeably enlarged during the surveillance angiography. The patient accepted balloon-assisted clipping successfully. Blister aneurysms are at a high risk of rupture, high risk of regrowth, and need for multimodal management.
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Abstract
Blister aneurysms are rare cerebrovascular lesions for which the treatment methods are reviewed here, with a focus on endovascular options. The reported pathogenesis of blister aneurysms varies, and hemodynamic stress, arterial dissection, and arteriosclerotic ulceration have all been described. There is consensus on the excessive fragility of blister aneurysms and their parent vessels, which makes clipping technically difficult. Open surgical treatment is associated with high rates of complications, morbidity, and mortality; endovascular treatment is a promising alternative. Among endovascular treatment options, deconstructive treatment has been associated with higher morbidity compared with reconstructive methods such as direct embolization, stent- or balloon-assisted direct embolization, stent monotherapy, and flow diversion. Flow diversion has been associated with higher technical success rates and similar clinical outcomes compared with non–flow diverting treatment methods. However, delayed aneurysm occlusion and the need for antiplatelet therapy are potential drawbacks to flow diversion that must be considered when choosing among treatment methods for blister aneurysms.
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Ji T, Guo Y, Huang X, Xu B, Xu K, Yu J. Current status of the treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery: A review. Int J Med Sci 2017; 14:390-402. [PMID: 28553172 PMCID: PMC5436482 DOI: 10.7150/ijms.17979] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 02/26/2017] [Indexed: 11/05/2022] Open
Abstract
Currently, the treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) is challenging and utilizes many therapeutic methods, including direct clipping and suturing, clipping after wrapping, clipping after suturing, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass. In these therapeutic approaches, the optimal treatment method for BBAs has not yet been defined based on the current understanding of BBAs of the supraclinoid ICA. Therefore, in this study, we aimed to review the literature from PubMed to discuss and analyze the pros and cons of the above approaches while adding our own viewpoints to the discussion. Among the surgical methods, direct clipping was the easiest method if the compensation of the collateral circulation of the intracranial distal ICA was sufficient or direct clipping did not induce stenosis in the parent artery. In addition, the clipping after wrapping technique should be chosen as the optimal surgical modality to prevent rebleeding from these lesions. Among the endovascular methods, multiple overlapping stents (≥3) with coils may be a feasible alternative for the treatment of ruptured BBAs. In addition, flow-diverting stents appear to have a higher rate of complete occlusion and a lower rate of retreatment and are a promising treatment method. Finally, when all treatments failed or the compensation of the collateral circulation of the intracranial distal ICA was insufficient, the extracranial-intracranial (EC-IC) arterial bypass associated with surgical or endovascular trapping, a complex and highly dangerous method, was used as the treatment of last resort.
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Affiliation(s)
- Tiefeng Ji
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Xiuying Huang
- Department of Operation, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Baofeng Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, P.R. China
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Byoun HS, Yi HJ, Choi KS, Chun HJ, Ko Y, Bak KH. Comparison of Endovascular Treatments of Ruptured Dissecting Aneurysms of the Intracranial Internal Carotid Artery and Vertebral Artery with a Review of the Literature. J Korean Neurosurg Soc 2016; 59:449-57. [PMID: 27651862 PMCID: PMC5028604 DOI: 10.3340/jkns.2016.59.5.449] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/03/2016] [Accepted: 05/16/2016] [Indexed: 11/27/2022] Open
Abstract
Objective Subarachnoid hemorrhage (SAH) caused by rupture of an internal carotid artery (ICA) or vertebral artery (VA) dissecting aneuryesm is rare. Various treatment strategies have been used for ruptured intracranial dissections. The purpose of this study is to compare the clinical and angiographic characteristics and outcomes of endovascular treatment for ruptured dissecting aneurysms of the intracranial ICA and VA. Methods The authors retrospectively reviewed a series of patients with SAH caused by ruptured intracranial ICA and VA dissecting aneurysms from March 2009 to April 2014. The relevant demographic and angiographic data were collected, categorized and analyzed with respect to the outcome. Results Fifteen patients were identified (6 ICAs and 9 VAs). The percentage of patients showing unfavorable initial clinical condition and a history of hypertension was higher in the VA group. The initial aneurysm detection rate and the percentage of fusiform aneurysms were higher in the VA group. In the ICA group, all patients were treated with double stent-assisted coiling, and showed favorable outcomes. In the VA group, 2 patients were treated with double stent-assisted coiling and 7 with endovascular trapping. Two patients died and 1 patient developed severe disability. Conclusion Clinically, grave initial clinical condition and hypertension were more frequent in the VA group. Angiographically, bleb-like aneurysms were more frequent in the ICA group and fusiform aneurysms were more frequent in the VA group. Endovascular treatment of these aneurysms is feasible and the result is acceptable in most instances.
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Affiliation(s)
- Hyoung Soo Byoun
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyeong Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Kyu Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyoung Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Yong Ko
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Koang Hum Bak
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
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Onofrj V, Cortes M, Tampieri D. The insidious appearance of the dissecting aneurysm: Imaging findings and related pathophysiology. A report of two cases. Interv Neuroradiol 2016; 22:638-642. [PMID: 27511816 DOI: 10.1177/1591019916659265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 06/22/2016] [Indexed: 11/15/2022] Open
Abstract
Intracranial dissecting aneurysms have been frequently reported to present with fairly challenging and time-variable imaging findings that can be mostly explained by the pathological mechanisms that underline the dissection. We present two cases of spontaneous dissecting aneurysm of the supraclinoid ICA, both clinically presenting with SAH, but characterized by different progression of clinical symptoms and imaging. However, in both cases an outpouch and a mild fusiform dilation of the supraclinoid ICA was present in the initial CTA performed after the occurrence of symptoms. These findings were well depicted by the MPR reformats performed retrospectively. We postulate that this finding may represent the point of initial transmural dissection and we recommend that careful analysis of the CTA MRP reformatted images should be performed in order to detect this finding promptly.
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Affiliation(s)
- Valeria Onofrj
- Department of Neuroradiology, Montreal Neurological Institute and Hospital, McGill University, Canada.,Dipartimento di Diagnostica Radiologica e Bioimmagini, Policlinico Agostino Gemelli, Italy
| | - Maria Cortes
- Department of Neuroradiology, Montreal Neurological Institute and Hospital, McGill University, Canada
| | - Donatella Tampieri
- Department of Neuroradiology, Montreal Neurological Institute and Hospital, McGill University, Canada
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Puri AS, Gounis MJ, Massari F, Howk M, Weaver J, Wakhloo AK. Republished: Monotherapy with stenting in subarachnoid hemorrhage (SAH) after middle cerebral artery dissection. J Neurointerv Surg 2015; 8:e13. [DOI: 10.1136/neurintsurg-2014-011596.rep] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 11/03/2022]
Abstract
Isolated middle cerebral artery dissection is a rare clinical entity, with descriptions limited to a few case reports and case series. Symptomatic dissection in the anterior circulation can present as an ischemic stroke in a young population; however, it is rarely associated with subarachnoid hemorrhage. We describe a young patient who presented with acute headache from a subarachnoid hemorrhage that was ultimately determined to be due to a vascular dissection in the middle cerebral artery. The initial angiogram showed vascular irregularities in this area with stenosis. Repeat imaging 4 days after presentation identified a pseudoaneurysm proximal to the stenosis. The patient was successfully treated with a self-expanding nitinol stent and followed up with serial angiography during postoperative recovery in the hospital; additional angiograms were performed approximately 1 and 6 months after treatment. Serial angiograms demonstrated incremental healing of the dissection. The patient was discharged and remains neurologically intact at the 6-month follow-up.
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Puri AS, Gounis MJ, Massari F, Howk M, Weaver J, Wakhloo AK. Monotherapy with stenting in subarachnoid hemorrhage (SAH) after middle cerebral artery dissection. BMJ Case Rep 2015; 2015:bcr-2014-011596. [PMID: 25833904 DOI: 10.1136/bcr-2014-011596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Isolated middle cerebral artery dissection is a rare clinical entity, with descriptions limited to a few case reports and case series. Symptomatic dissection in the anterior circulation can present as an ischemic stroke in a young population; however, it is rarely associated with subarachnoid hemorrhage. We describe a young patient who presented with acute headache from a subarachnoid hemorrhage that was ultimately determined to be due to a vascular dissection in the middle cerebral artery. The initial angiogram showed vascular irregularities in this area with stenosis. Repeat imaging 4 days after presentation identified a pseudoaneurysm proximal to the stenosis. The patient was successfully treated with a self-expanding nitinol stent and followed up with serial angiography during postoperative recovery in the hospital; additional angiograms were performed approximately 1 and 6 months after treatment. Serial angiograms demonstrated incremental healing of the dissection. The patient was discharged and remains neurologically intact at the 6-month follow-up.
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Affiliation(s)
- Ajit S Puri
- Department of Radiology, New England Center for Stroke Research and Division Neuroimaging and Intervention, Worcester, Massachusetts, USA
| | - Matthew J Gounis
- Department of Radiology, New England Center for Stroke Research and Division Neuroimaging and Intervention, Worcester, Massachusetts, USA
| | - Francesco Massari
- Department of Radiology, New England Center for Stroke Research and Division Neuroimaging and Intervention, Worcester, Massachusetts, USA
| | - Mary Howk
- Department of Radiology, New England Center for Stroke Research and Division Neuroimaging and Intervention, Worcester, Massachusetts, USA
| | - John Weaver
- Department of Neurosurgery, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Ajay K Wakhloo
- Department of Radiology, New England Center for Stroke Research and Division Neuroimaging and Intervention, Worcester, Massachusetts, USA
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