Endovascular intervention vs. microsurgery on the prognosis of anterior circulation blood blister-like aneurysm: A cohort study

Treating blood blister-like aneurysms (BBA) is a major neurosurgical challenge. Whether endovascular repair serves as a better strategy than microsurgery remains controversial. We aim to perform a propensity score-matched (PSM) retrospective study to analyze the short-term outcome in BBA patients who received microsurgery and endovascular treatment. One hundred fifty-five eligible patients with internal carotid artery BBA were retrospectively collected with demographic and angiographic baseline in a single center. Three-month outcome and adverse events were set as outcome endpoints. PSM was used to match the microsurgery and endovascular group. Matching effect was evaluated by distribution variation analysis and love plot. The outcome of neurosurgery and endovascular treatment was then compared before and after PSM. Better WFNS levels (p = .017) and modified Fisher grade (p = .027) were noted in endovascular group before matching. Other baseline including angiographic features were comparable between two groups. Before matching, the 3-month outcome of endovascular repair surgery was more favorable than microsurgery (p < .0001). The occurrence of adverse events was also higher in the microsurgery group (p = .0079). In PSM-adjusted groups, the superior outcome effect of endovascular treatment still existed but with a reduced significance (p = .004). Similar trend was also observed in the adverse event rate (p = .038). Fatality rate was comparable between two adjusted groups regardless of PSM adjustment. Endovascular surgery of BBAs exhibits overall more favorable short-term outcome regardless of PSM matching. Microsurgery does not cause a higher fatality rate, hence it could be considered a salvage plan for those high-grade BBA patients.

Journal of Cardiac SurgeryVolume 32, Issue 1 p. 28-29 IMAGES IN CARDIAC SURGERY Lacerated anterior mitral valve leaflet following percutaneous balloon valvuloplasty Qian Lei MD, Corresponding Author Qian Lei MD leiqianggh@163.com Department of Anesthesiology and Cardiac Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China Correspondence Qian Lei MD, Department of Anesthesiology, Sichuan Provincial People's Hospital, Chengdu 610072, China. Email: leiqianggh@163.comSearch for more papers by this authorXinchuan Wei MD, Xinchuan Wei MD Department of Anesthesiology and Cardiac Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, ChinaSearch for more papers by this authorKeli Huang MD, Keli Huang MD Department of Anesthesiology and Cardiac Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, ChinaSearch for more papers by this authorBin Xie MD, Bin Xie MD Department of Cardiac Surgery, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, ChinaSearch for more papers by this author Qian Lei MD, Corresponding Author Qian Lei MD leiqianggh@163.com Department of Anesthesiology and Cardiac Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China Correspondence Qian Lei MD, Department of Anesthesiology, Sichuan Provincial People's Hospital, Chengdu 610072, China. Email: leiqianggh@163.comSearch for more papers by this authorXinchuan Wei MD, Xinchuan Wei MD Department of Anesthesiology and Cardiac Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, ChinaSearch for more papers by this authorKeli Huang MD, Keli Huang MD Department of Anesthesiology and Cardiac Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, ChinaSearch for more papers by this authorBin Xie MD, Bin Xie MD Department of Cardiac Surgery, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, ChinaSearch for more papers by this author First published: 27 November 2016 https://doi.org/10.1111/jocs.12876Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume32, Issue1January 2017Pages 28-29 RelatedInformation

Rare CT manifestions of an asymptomatic girl with COVID-19.

Microsurgical versus Endovascular Treatments for Blood-Blister Aneurysms of the Internal Carotid Artery: A Retrospective Study of 83 Patients in a Single Center

Our study aimed to evaluate the outcome of patients with ruptured blood-blister like aneurysm (BBLA) in our institution by comparing microsurgical selective treatment to endovascular treatment using flow-diverter stent (FD). Our study included 18 consecutive patients treated for BBLA between 2004 and 2020. Until 2014, microsurgery was preferred in all patients with BBLA (n = 10). Significant postoperative morbi-mortality was recorded at this time and led us to change therapeutic strategy and to favor FD as first-line treatment in all patients (n = 8). Postprocedural complications and BBLA occlusion were recorded. High WFNS score (> 2) was noted in 6 patients of microsurgical group and in 2 of endovascular group. In microsurgical group, ischemic lesions were noted in 6 patients and led to death in 3 patients. Immediate BBLA occlusion was obtained in all patients. Favorable outcome after 3months (mRS < 3) was recorded in 4 of the 7 survivors. In endovascular group, ischemic lesions were noted in 4 patients. One patient died from early postprocedural BBLA rebleeding. Scarpa hematoma was noted in 3 patients with surgical evacuation in 1. Persistent BBLA at 3months was recorded in 4 patients without rebleeding, but further FD was required in 1 with growing BBLA. Favorable outcome was noted in 6 of the 7 survivors. Although, rate of morbi-mortality appear lower in patients treated with FD, neurological presentation was better and BBLA diagnosis remains questionable in this group. Moreover, persistent BBLA imaging with potential risk of rebleeding after FD deserves to be discussed.

Ruptured blood blister-like aneurysms (BBAs) are rare and very difficult to treat. The optimal treatment of BBAs has yet to be clearly established. Reconstructive endovascular treatment (EVT) of this type of lesion has been recently tried with multiple stents together with or without coiling, and this is expected to have a flow diversion effect [1–3]. Herein, we report on a case with repeated recurrence of a BBA after initial treatment with three overlapping Enterprise stents (Codman Neurovascular, Miami Lake, FL, USA) and coiling, and the lesion was finally completely obliterated using five Enterprise stents with coiling. To the best of our knowledge, this is the first case that five overlapping stents were deployed in the same site of the intracranial vessel with 1-year follow-up. A 41-year-old woman was admitted to our institute with severe, sudden-onset headache. She was alert without any neurological deficit. Brain computed tomography revealed bilateral sylvian obliteration and a magnetic resonance image showed subarachnoid hemorrhage on the FLAIR image. Right internal carotid artery (ICA) angiography demonstrated a small hemispherical bulge at the anterolateral wall of the communicating segment of the ICA (Fig. 1a). Because of its typical location and shape, this lesion was diagnosed as a BBA. Initially, we discussed performing segmental occlusion of the right ICA, which was bearing the BBA. However, this option was abandoned because of the poor collateral circulation and the patient’s intolerance to a right ICA occlusion test. Other treatment options such as microsurgical clipping, wrapping and/or trapping with bypass were dropped out because of the high risk of intraoperative bleeding and the difficulty of the technique. Thus, we planned to perform stentassisted coil embolization with multiple overlapping stents. At the beginning of the procedure, loading doses of clopidogrel 300 mg and aspirin 200 mg were given orally. A 6-Fr guiding catheter (Envoy; Codman Neurovascular) was positioned at the distal cervical portion of the right ICA. The right middle cerebral artery (MCA) was navigated using a microcatheter (Prowler Select Plus; Codman Neurovascular) and a microwire. A 4.5 mm 9 28 mm Enterprise stent was loaded through the catheter and it was ready for deployment. A second microcatheter (Excelsior; Boston Scientific, Natick, MA, USA) was then placed into the BBA. After the stent was fully deployed, two coils were inserted into the BBA. An additional Enterprise stent (4.5 mm 9 22 mm) was introduced and positioned, such that it overlapped the previous stent for remodeling the blood flow away from the BBA. Three more coils were inserted into the BBA. Finally, the third Enterprise stent (4.5 mm 9 28 mm) was deployed to further reinforce the flow diversion effect away from the BBA. Right ICA angiography showed near complete obliteration of the BBA (Fig. 1b). The 6-day follow-up angiography showed a neck recurrence (Fig. 1c), which was retreated with further coiling on the same day, and this resulted in complete obliteration (Fig. 1d). Follow-up angiography 2 weeks after the second treatment revealed no evidence of recanalization J. Chung Department of Neurosurgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea

Objective: To explore the clinical characteristics, therapeutic methods and effects of blood blister-like aneurysms (BBA) of the supraclinoid segment of the internal carotid artery (ICA). Methods: A total of 40 patients with BBAs of the ICA treated at Department of Neurosurgery of West China Hospital between January 2010 and January 2016 were retrospectively reviewed. There were 14 males and 26 females with the mean age of 44.7 years (ranging from 25 to 64 years). There were 38 patients presented with subarachnoid hemorrhage (SAH), and 2 patients were found incidentally with unruptured aneurysms in regular examination. Surgical treatment was performed in 22 patients, including direct clipping, clipping over wrapping and trapping. Endovascular treatment with single or multiple stents and coiling was performed in 18 patients. Clinical outcomes were assessed with modified Rankin Scale. The patients were followed up with CT angiography. Results: Direct clipping of BBA was performed in 18 patients, clipping over wrapping in 3 patients and trapping of ICA in 1 patient. Intraoperative rupture occurred in 5 patients. Postoperative cerebral infarction developed in 6 cases, 4 patients died. Single stent-assisted coiling was performed in 8 cases, and multiple stents with coiling in 10 patients. Procedure-related hemorrhage occurred in 2 patients, postoperative massive cerebral infarction developed in 1 patient with stent-assisted coiling. The follow-up time was 26.8 months (ranging from 6 to 72 months), among the patients with surgery, good results (modified Rankin Scale 0-2) were achieved in 16 patients; one patient was score 3, and the other was 4. In endovascular group, 15 patients had good results and one with mRS 4. Follow-up angiography revealed recurrence of BBA in 2 patients treated with stent and coiling, which was retreated with coiling. No recurrence was found in surgical group. Conclusions: BBA of the supraclinoid ICA is a specific and complicated intracranial aneurysm with high risk and complications no matter the treatment is surgical or endovascular, take proper operation methods could achieve satisfactory results.

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. 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. 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. 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.

BackgroundAcute 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.MethodsFrom 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.ResultsBased 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.ConclusionsAcute 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.

Blood blister-like aneurysms in Tibetans: A retrospective observational study

Introduction: Blood blister-like (BBAs) aneurysms are rare cerebrovascular lesions for which the endovascular treatment methods are reviewed here. The reported pathogenesis varies, and hemodynamic stress, arterial dissection, and arteriosclerotic ulceration have all been described. The excessive fragility of BBAs and their parent vessels, can make microsurgical clipping technically difficult. Surgical treatment is associated with high rates of complications, morbidity, and mortality. The approach to the treatment of BBAs in recent times has shifted from microsurgical treatment to endovascular treatment, thanks to ongoing innovations in regard to endovascular techniques and devices. Method: The authors performed a review of available endovascular techniques used for blood blister-like aneurysms treatment. The Pubmed database was used as source search introducing “blood blister-like aneurysm” and “blister aneurysms” as keywords. The most relevant articles and those that focused on endovascular treatment techniques were selected. Discussion: Endovascular interventional techniques have evolved as an effective treatment for intracranial aneurysms. Considerable interest has emerged regarding the use of endovascular approaches to treat BBAs. In some studies, endovascular treatment of BBAs was associated with high rates of complete occlusion and good mid- to long-term neurological outcomes. Various endovascular techniques have been applied to treat BBAs, such as coil embolization, stenting, stent-assisted coiling and flow-diverting stents. Conclusion: From the available endovascular techniques, flow-diverting stents appears to be the safest and most effective treatment modality, with a higher rate of complete occlusion of an aneurysm and a lower rate of retreatment. The development of novel flow-diverting stents with decreased thrombogenic properties, may represents a key step forward and increases the potential for flow diversion becoming the gold standard for endovascular treatment of BBAs.Keywords: Intracranial aneurysm; Aneurysm, ruptured; Carotid artery disease; Subarachnoid hemorrhage; Endovascular procedures

Fragile aneurysm walls and poorly defined necks render the surgical treatment of blood blister–like aneurysms (BBAs) located at nonbranching sites of the supraclinoid internal carotid artery extremely challenging. Such aneurysms have a remarkable tendency to rupture during surgery, especially during the acute period. The authors describe the clinical course of patients with subarachnoid hemorrhage (SAH) caused by BBA rupture and emphasize the value of internal carotid artery trapping combined with high-flow extracranial-intracranial (trapping/EC-IC) bypass during the acute period following SAH. The authors analyzed the clinical records of 7 consecutive female patients with a mean age of 61 years (range 51–77 years) who had been treated between January 2006 and December 2008 at their institute. All 7 patients presented with SAHs corresponding to Fisher Grade 3 and World Federation of Neurosurgical Societies Grades II, III, IV, and V in 3, 1, 2, and 1 patient, respectively. Surgery was postponed in the 3 patients, including 1 in whom the trapping/EC-IC bypass procedure was performed during the chronic period. Two of the 3 patients in whom surgery was postponed experienced preoperative rebleeding, and repeated angiography revealed remarkable enlargement of the aneurysm; both of these patients died before surgery could be performed. The remaining 4 patients underwent trapping/EC-IC bypass during the acute period following SAH. The outcome was excellent (Glasgow Outcome Scale Scores 5), and postoperative angiography demonstrated complete obliteration of the BBA as well as good graft patency in all 5 patients who underwent trapping/EC-IC bypass. Intraoperative bleeding from the BBAs never occurred in any of these 5 patients. Ruptured BBAs were successfully treated with a trapping/EC-IC bypass during the acute SAH period. This surgical strategy for treating BBAs during the acute period might be a promising option for these rare but high-risk lesions.

Flow diverters (FDs) have shown the potential to treat blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA). We report a series of cases treated by both deploying FDs and coiling. Based on the Bojanowski classification, the BBAs of the supraclinoid ICA were classified into types I-IV. Based on the approach used for endovascular treatment (EVT) of the BBAs, the EVTs were categorized into types 1-3. The modified Rankin scale (mRS) was used to assess the clinical follow-up outcome. Thirteen patients with 13 BBAs of the supraclinoid ICA who were aged 22-66 (49.8 ± 13.5) years were included. There were 12 females and 1 male. All patients had experienced subarachnoid hemorrhage. According to the Bojanowski's et al. classification, a total of 2, 7, 3, and 1 BBAs were categorized as types I, II, III, and IV, respectively. Preoperative vasospasms were detected in 4 patients. EVT types 1, 2, and 3 were used to treat 4, 7, and 2 BBAs, respectively. After EVT, 2 patients with preoperative vasospasm experienced hemiparesis but later recovered. One patient with a preoperative vasospasm experienced multiple infarctions and died. One patient who discontinued antiplatelet therapy experienced multiple infarctions and suffered severe disability. ‌Twelve patients completed a post-EVT six-month follow-up, excluding the one with postoperative mortality.‌ The mRS scores were 0, 1, and 4 for 10, 1, and 1 patients, respectively. Eleven patients were subjected to angiographic follow-up. All BBAs were cured, and the supraclinoid ICAs were repaired. For patients with BBAs, deploying an FD and coiling can yield good outcomes. However, ischemic complications should not be overlooked.

Object Blood blister-like aneurysms (BBA) are aneurysms arising from the non-branching arterial trunk, which are usually small and located at the dorsal wall of supraclinoid internal carotid artery (ICA). These aneurysms are quite dangerous due to their fragile neck. This paper aims to evaluate the application of endovascular treatments in the treatment of BBA. Methods Four hundred fifty-one patients diagnosed with aneurysmal SAH between Aug. 2010 and Dec. 2014 were collected at the Catholic University of Korea, Saint Vincent’s hospital. Thirteen patients had ICA dorsal wall aneurysms. A retrospective review of the aneurysm database in our institution identified 12 patients carrying ICA dorsal wall aneurysm planned to be treated by endovascular treatments. The clinical characteristics, angiographic outcome, and follow-up results were reviewed. Clinical characteristics included age, gender, Hunt and Hess grade, modified Fisher grade, type of treatment (coil embolization, surgical clipping), aneurysm type. Results Stent-assisted coil embolization was successfully performed in 10 cases (83.3%). In terms of the stent usage, 2 patients were treated with single stent (16.6%), 2 patients were treated with double stent (16.6%), and 6 patients were treated with triple stent (50%). Six patients had rapid configurational changes during the treatment course (50%). Because rapid growth of this type of aneurysm had high re-bleeding tendency, we decided multiple stent deploying. In spite of multiple stent-assisted coil embolization, one patient occurred regrowth. All patients were followed up angiographically, and regrowth was observed in two patients (16.6%), one case was treated by further endovascular treatments without complications and another case was observed due to obliteration by thrombosed. The modified Rankin scale (mRS) score in living patients at discharge was 0 in five cases, 1 in one case, 3 in one case, and 4 in two cases. One patient died of severe brain edema. The mRS score at 1–57 months’ follow-up was 0 in eight cases, 2 in one case, and 4 in two cases. Conclusions Because rapid growth of aneurysm had high re-bleeding tendency, we had done multiple stent deploying. The results of endovascular procedures of this type of aneurysm are satisfactory. But we don’t know yet, how many stents are enough. However multiple stent-assisted coil embolization can be considered as an alternative treatment option for rapid-growing dorsal wall aneurysms. Disclosures D. Lee: None. J. Sung: None. J. Huh: None. Y. Ihn: None. S. Lee: None.

ObjectiveBlood blister-like aneurysms (BBAs) resemble arterial dissections. The purpose of this study was to investigate the relationship between these two disease entities and highlight commonalities and distinct features.MethodsAmong 871 consecutive patients with aneurysmal subarachnoid hemorrhage, 11 BBAs of internal carotid artery and seven vertebral artery dissections (VADs) with a short segmental eccentric dilatation (Mizutani type 4), which is morphologically similar to a BBA, were selected. The following clinical factors were studied in each group : age, gender, risk factors, Hunt and Hess grade (HHG), Fisher grade (FG), vasospasms, hydrocephalus, perioperative rebleeding rate, and treatment outcome.ResultsThe mean age was 47.9 years in the BBAs group and 46.4 years in the type 4 VADs group. All the BBA patients were female, whereas there was a slight male predominance in the type 4 VAD group (male : female ratio of 4 : 3). In the BBA and type 4 VAD groups that underwent less aggressive treatment to save the parent artery, 29% (n=2/7) and 66.6% (n=2/3), respectively, eventually required retreatment. Perioperative rebleeding occurred in 72.7% (n=8) and 28.6% (n=2) of patients in the BBA and type 4 VAD groups, respectively. There was no statistical difference in the other clinical factors in both groups, except for the male dominancy in the type 4 VAD group (p=0.011).ConclusionBBAs and ruptured type 4 VADs have a similar morphological appearance but there is a distinct clinical feature in gender and perioperative rebleeding rates. Complete isolation of an aneurysm from the parent artery might be the most important discipline for the treatment of these diseases.