Five overlapping enterprise stents in the internal carotid artery-to-middle cerebral artery to treat a ruptured blood blister-like aneurysm

Abstract

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