Blister Aneurysms Research Articles

The Experience With Flow Diverters in the Treatment of Posterior Inferior Cerebellar Artery Aneurysms.

The use of the pipeline embolization device (PED; Medtronic, Dublin, Ireland) in the posterior circulation has been limited and infrequently reported compared to other off-label utilizations. Posterior inferior cerebellar artery aneurysms (PICAA) constitute 1 of the least reported posterior circulation aneurysms treated with PED. No clinical studies have addressed the treatment of these aneurysms with flow diversion exclusively. To appraise the feasibility and the safety of PED in the treatment of PICAAs. Data on 12 consecutive patients, treated between 2011-2017 with PED for their PICAA, was retrospectively reviewed. To control confounding, we used multivariable logistic regression and propensity score conditioning. Of 534 patients, 12 (9/12, 75% males) were identified and constituted our study population. The average aneurysm size was 8.47 mm (SD = 2.6, 3.7-14). Patients were followed-up for an average of 10.3 months (SD = 11 mo). Two of 12 (16.7%) had a prior history of subarachnoid hemorrhage. Eight of 12 (67%) of the aneurysms were saccular, 3/12 (25%) were dolichoectatic, and 1/12 (8%) was a small blister aneurysm. Eleven of 12 (92%) aneurysms were treated with 1 PED; 2/12 (16.7%) patients received combined pipeline assisted coiling. All patients had a complete occlusion, regression, and resolution of their aneurysm(s). PED deployment was neither complicated with any hemorrhagic or clinically significant thromboembolic events nor with device migration in any of our patients. Three of 12 (25%) patients had a benign intrastent stenosis. No mortality, among our 12 patients, was noted throughout the follow-up period. PED, deployed by specialized experts, should be safe in treating PICAA. It can be contemplated as a novel alternative treatment of aneurysms located at the PICA-VA bifurcation or within the PICA.

Single-center experience with the new generation Derivo Embolization Device in ruptured dissecting and blister aneurysms.

Treatment of ruptured dissecting and blister aneurysms is technically challenging with potentially high morbidity and mortality. The Derivo Embolisation Device (Derivo) is a flow diverter stent designed for the treatment of intracranial aneurysms. To assess the safety and feasibility of the Derivo in the treatment of ruptured dissecting and blister aneurysms. We retrospectively analyzed all patients with ruptured dissecting and blister aneurysms treated with the Derivo between February 2016 and July 2018. Procedural details, complications, morbidity within 30 days, and angiographic aneurysm occlusion rates, initially and after six months, were assessed. In 10 patients 11 ruptured dissecting and blister aneurysms were treated with 12 Derivos as monotherapy. No aneurysm rebleeding was observed at follow-up. One treatment-related complication occurred including a coil perforation of an additionally treated aneurysm. One patient died due to brain edema. Initial digital subtraction angiography revealed complete (O'Kelly-Marotta [OKM] classification D) and favorable (OKM D+C) occlusion rate in three aneurysms. Six-month follow-up for digital subtraction angiography and clinical evaluation was available in 6/9 patients with complete (OKM D) occlusion in all aneurysms (6/6). Favorable (modified Rankin Scale [mRS] ≤ 2) and moderate (mRS 3) clinical outcome after a mean follow-up of 10 months was observed in six and two patients, respectively. Endovascular treatment with the Derivo in ruptured dissecting and blister aneurysms revealed a sufficient initial division of aneurysms from the circulation without rebleeding. The Derivo is associated with high procedural and clinical short-term safety.

A hybrid operating room for combined surgical and endovascular procedures for cerebrovascular diseases: a clinical experience at a single centre

Purpose: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).Material and methods: A single-plane DSA system with 3-dimensional rotational angiography (3DRA), cone-beam computed tomography, and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of neurovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorised into five subcategorical procedures according to the dominance of surgical and/or endovascular procedures: intraoperative angiographic evaluation, combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, surgical approach for interventional procedure, and frameless stereotaxic operation.Results: Intraoperative angiography revealed unsatisfactory clipping of intracranial aneurysms in 6 (13.6%) patients and remnant AVMs in 1 (16.7%) patient, which were determined as complete surgical outcome via indocyanine green videoangiography. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial haemorrhage (ICH) were treated by partial embolisation and surgical clipping. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolisation. In 1 (0.8%) complicated case of 103 intra-arterial (IA) thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. Direct puncture of the common carotid artery or vertebral artery was performed to achieve interventional access to treat aneurysm or recanalise vessel occlusions in 7 cases. In 27 cases of ICH, frameless stereotaxic haematoma aspiration was performed using XperGuide® system. All procedures were performed in single sessions without any procedural complications.Conclusion: Hybrid OR with a fully equipped DSA system could provide safe and precise treatment for neurovascular diseases. Hybrid procedures for neurovascular diseases in hybrid OR are a promising new trend.

Microsurgical Management of Ruptured Blood Blister Aneurysms of the Internal Carotid Artery without Bypass: A Retrospective Single-Center Study of 36 Patients over 20 Years

Microsurgical management of blood blister aneurysms of the internal carotid artery is challenging because of the special characteristics of these aneurysms. We reviewed our diverse surgical methods with long-term clinical and radiologic follow-up. We retrospectively reviewed all patients with blood blister aneurysms presenting with subarachnoid hemorrhage that were treated with microsurgical obliteration between 1993 and 2017. Baseline characteristics of patients and aneurysms, surgical methods, and clinical and radiologic outcomes were analyzed. This study included 36 patients. The patients were treated using microsurgery with direct clipping (2 patients; 5.6%), cotton-assisted clipping (24 patients; 66.7%), wrapping-clipping (5 patients; 13.9%), or wrapping-clipping with suturing (5 patients; 13.9%). Complete occlusion of aneurysm was achieved in 34 of 36 patients (94.4%). Severe vasospasm developed in 18 of 36 patients (50%). Ischemic events occurred in 8 patients (22.2%), 2 of whom remained with severe disability. Regrowth or recurrence occurred in 1 patient (0.28%), which required additional stent-assisted coil embolization. Mean modified Rankin Scale score was 2.0 (median, 1.0; range, 0-4) at discharge and 1.3 (median, 1.0; range, 0-4) at the last follow-up. Direct clipping is ideal if possible; however, direct clipping is challenging in most blood blister aneurysms. Assisted clipping with cotton is mainly used and could be an effective technique for reinforcement of the friable wall, with good clinical outcomes in our series. Moreover, suturing followed by wrapping-clipping is also useful for managing intraoperative rupture.

Blister aneurysms of the internal carotid artery: Surgical treatment and management outcome from a single center experience

ObjectiveBlood-blister aneurysms (BBAs) of the internal carotid artery (ICA) are rare entities, but clinically important cause of subarachnoid hemorrhage (SAH). Several surgical and endovascular strategies have been attempted for these heterogeneous lesions. In this study, the authors analyzed the treatment strategy and outcomes in a series of cases of ICA blister aneurysms treated microsurgically. Patients and methodsWe retrospectively reviewed 15 consecutive cases of patients harboring ruptured BBAs, microsurgically treated at our institution between 2014 and 2018. We performed an analysis of the clinical and surgical aspects, as well as post-operative angiograms and outcomes. ResultsFifteen patients were identified; 9 (60%) were female. The mean age of presentation was 43,8 years. Most patients presented in good clinical conditions (Hunt-Hess 1–3 = 86%). The most common Fisher grade at presentation was 3 (60% of cases). All patients underwent digital subtraction angiography (DSA), revealing broad-based aneurysms at non-branching sites on the dorsal wall of the ICA. Intraoperatively, BBAs were confirmed in all cases. The lesions were approached through pterional (11–73%) or lateral supraorbital (4–27%) craniotomy. Direct clipping was performed in all but one lesion, in which case the clip-wrapping technique was used. Final angiographic control revealed complete occlusion in 14 cases. One patient required reoperation due to residual aneurysm filling. At discharge, a good outcome (Glasgow Outcome Scale [GOS] 4 or 5) was observed in 12 (80%) patients. Three patients were discharged with a GOS of 3. ConclusionBlood-blister-type aneurysms are rare and challenging lesions. Preoperative knowledge and careful surgical planning can prevent poor clinical outcomes. Surgical treatment remains an effective and safe option in this context.

Tissue-engineered aneurysm models for in vitro assessment of neurovascular devices.

Preclinical testing of neurovascular devices is crucial for successful device design and is commonly performed using in vivo organisms such as the rabbit elastase-induced aneurysm model; however, simple in vitro models may help further refine this testing paradigm. The purpose of the current work was to evaluate, and further develop, tissue-engineered blood vessel mimics (BVMs) as simple, early-stage models to assess neurovascular devices in vitro prior to animal or clinical use. The first part of this work used standard straight-vessel BVMs to evaluate flow diverters at 1, 3, and 5 days post-deployment. The second part developed custom aneurysm-shaped scaffolds to create aneurysm BVMs. Aneurysm scaffolds were characterized based on overall dimensions and microstructural features and then used for cell deposition and vessel cultivation. It was feasible to deploy flow diverters within standard BVMs and cellular linings could withstand and respond to implanted devices, with increasing cell coverage over time. This provided the motivation and foundation for the second phase of work, where methods were successfully developed to create saccular, fusiform, and blister aneurysm scaffolds using a wax molding process. Results demonstrated appropriate fiber morphology within different aneurysm shapes, consistent cell deposition, and successful cultivation of aneurysm BVMs. It is feasible to use tissue-engineered BVMs for assessing cellular responses to flow diverters, and to create custom aneurysm BVMs. This supports future use of these models for simple, early-stage in vitro testing of flow diverters and other neurovascular devices.

Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial.

A direct comparison of endovascular versus microsurgical treatment of ruptured middle cerebral artery (MCA) aneurysms in randomized trials is lacking. As endovascular treatment strategies continue to evolve, the number of reports of endovascular treatment of these lesions is increasing. Herein, the authors report a detailed post hoc analysis of ruptured MCA aneurysms treated by microsurgical clipping from the Barrow Ruptured Aneurysm Trial (BRAT). The cases of patients enrolled in the BRAT who underwent microsurgical clipping for a ruptured MCA aneurysm were reviewed. Characteristics of patients and their clinical outcomes and long-term angiographic results were analyzed. Fifty patients underwent microsurgical clipping of a ruptured MCA aneurysm in the BRAT, including 21 who crossed over from the endovascular treatment arm. Four patients with nonsaccular (e.g., dissecting, fusiform, or blister) aneurysms were excluded, leaving 46 patients for analysis. Most (n = 32; 70%) patients presented with a Hunt and Hess grade II or III subarachnoid hemorrhage, with a high prevalence of intraparenchymal blood (n = 23; 50%), intraventricular blood (n = 21; 46%), or both. At the last follow-up (up to 6 years after treatment), clinical outcomes were good (modified Rankin Scale score 0–2) in 70% (n = 19) of 27 Hunt and Hess grades I–III patients and in 36% (n = 4) of 11 Hunt and Hess grade IV or V patients. There were no instances of rebleeding after the surgical clipping of aneurysms in this series at the time of last clinical follow-up. Microsurgical clipping of ruptured MCA aneurysms has several advantages over endovascular treatment, including durability over time. The authors report detailed outcome data of patients with ruptured MCA aneurysms who underwent microsurgical clipping as part of a prospective, randomized trial. These results should be used for comparison with future endovascular and surgical series to ensure that the best results are being achieved for patients with ruptured MCA aneurysms.

Direct cover-clip for ICA blood blister-like aneurysm

Abstract Blood blister aneurysm (BBA) is the aneurysm characterized by fragile neck usually arising from the dorsal wall of internal carotid artery (ICA). Application of aneurysm clip on the neck of BBA usually tears out the wall of the parent artery, leaving a defect on ICA. Trapping of ICA or fail to control bleeding may cause death of patient. Although various surgical procedures were proposed, there is no consensus with regard to the best option for the treatment of BBA. Direct clipping is a simple and fast way to treat BBA, which avoids long time temporary occlusion of ICA, prevents the occurrence of brain ischemia, and provide direct observation of clipping under microscope. We report a rescue technique direct “cover-clip” for intraoperative rupture of BBA in this paper.

Pipeline Embolization of Vertebrobasilar Aneurysms—A Multicenter Case Series

The Pipeline Embolization Device (PED) has been increasingly used for the treatment of posterior circulation aneurysms. The purpose of the present study was to examine the clinical and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. We performed a retrospective review of vertebrobasilar aneurysms treated with the PED at 4 high-volume neurovascular centers. Patient, aneurysm, and procedural data were collected, including perioperative and delayed complications. Aneurysm occlusion on follow-up imaging studies was defined as complete (100%), near-complete (>90%), or incomplete (<90%) occlusion. The cohort included 35 patients with 37 vertebrobasilar aneurysms who underwent 36 treatment sessions. Of the 35 patients, 10 were men (29%), and the mean patient age was 54.1 years (range, 32-75). Eight patients (23%) underwent urgent treatment because of a ruptured aneurysm (n= 6), brainstem perforator stroke (n= 1), or post-traumatic pseudoaneurysm (n= 1). Of the 37 aneurysms, 22 arose from the vertebral artery (59%) and 15 from the basilar artery (41%). Also, 19 were saccular aneurysms (51%), with a mean size of 7.7 mm (range, 1.7-38.0); 17 were fusiform aneurysms (46%), with a mean size of 11.0 mm (range, 4.3-34); and 1 was a 2.9-mm blister aneurysm. The overall procedural complication rate was 14% (5 of 36), including 3 neurologically symptomatic complications. At a mean follow-up period of 14 months (range, 3-59), 24 of 34 aneurysms (71%) were completely occluded and 29 of 34 (85%) were completely or near-completely occluded. Our results show that Pipeline embolization of vertebrobasilar aneurysms is associated with acceptable occlusion and complication rates.

Spontaneous Disappearance of a Ruptured Intracranial Aneurysm

The spontaneous disappearance of a ruptured intracranial aneurysm is unusual and its mechanism remains incompletely understood. However, several hypotheses are put forward and are mostly found in Virchow’s triad. We report the case of a man who suffered subarachnoid hemorrhage by rupture of a blister aneurysm of the P1 segment of the left posterior cerebral artery. A control arteriography performed one week after the rupture showed a disappearance of the aneurysm and a significant vasospasm of the carrier artery. Angiograms performed at 3 weeks and 3 months confirmed this disappearance of the aneurysm and a return to normal artery size. Clinically the patient was doing well. Therefore his aneurysm was spontaneously declared cured. Several studies are needed to clarify the natural history of spontaneously thrombosed aneurysms and elucidate their occurrence mechanism in order to improve the management of intracranial aneurysmal pathology.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease.

ObjectiveTo describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).MethodsA single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.ResultsForty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.ConclusionHybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

Blister like aneurysm: a review about its endovascular management / Aneurismas Blister-Like: uma revisão sobre seu tratamento endovascular

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

Application of the Willis Covered Stent in the Treatment of Ophthalmic Artery Segment Aneurysms: A Single-Center Experience

The purpose of this study is to introduce our initial experience with the evaluation of the feasibility of using Willis covered stents (WCSs) in the treatment of complicated ophthalmic artery (OA) segment aneurysms. Of the 162 patients with OA segment aneurysms treated by endovascular techniques in West China Hospital from January 2015 to August 2017, a total of 26 patients treated with WCSs were included in the study. Twenty-six patients with 26 aneurysms were included (mean age, 57.0 years; range, 22-76 years). The cohort had 20 patients with large or giant aneurysms, 3 patients with blood blister aneurysms, and 3 patients with pseudoaneurysms. Ten aneurysms were OA type, and 16 were internal carotid artery (ICA) type. Twenty-four patients were treated with 1 stent, and 2 patients were treated with 2 stents. Among the 26 patients, 2 patients had minimal endoleak, and 24 patients had complete occlusion after immediate postoperative angiography. One patient who had complete occlusion experienced contrast agent extravasation, and this phenomenon disappeared by balloon compression during the procedure. The 3- to 15-month angiographic follow-up showed that all patients experienced complete occlusion, including 2 patients with minimal endoleak during immediate postprocedural angiography. Two patient showed signs of in-stent stenosis. Clinical follow-up demonstrated that no delayed thromboembolic or ischemic events were recorded in the stent-grafted vascular region and no bleeding occurred in any of the patients (except 1 patient who experienced subarachnoid hemorrhage, left frontal lobe hemorrhage, and hydrocephalus 10 days after the procedure). WCSs may provide an alternative solution for treating complex OA segment aneurysms by reconstruction and preservation of the ICA. Our study also confirms the safety, efficacy, and midterm durability of WCSs for complex OA segment aneurysms.

Endovascular Management of Cerebral Aneurysm: The Recent Trends

AbstractCerebral aneurysm rupture is the leading cause of mortality and morbidity in patients with hemorrhagic stroke. Surgical clipping and endovascular coiling are the mainstay of management for securing the aneurysm. After International Subarachnoid Aneurysm Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) results, worldwide trend has shifted gradually in favor of endovascular management. Nonetheless, endovascular management was faced with some limitations, especially while treating giant, wide neck bifurcation, blister, and small uncoilable aneurysm. The recent introduction of new devices such as flow diverter stents, microstents, bifurcation devices, double-lumen balloon catheters, and microcoils have proved to be effective in overcoming the limitations of traditional aneurysm coiling. The authors present a review of recent advances in the endovascular management of cerebral aneurysm.

Extracranial-Intracranial Bypass for Treatment of Blister Aneurysms: Efficacy and Analysis of Complications Compared with Alternative Treatment Strategies

Blister aneurysms (BAs) represent a clinical challenge without a consensus treatment strategy. We report our institution's experience with BAs with an emphasis on the use of extracranial-to-intracranial (EC-IC) bypass. Seventeen patients with BAs (88% [15/17] ruptured) were treated with microsurgical techniques (5 clip wrappings, 4 clip ligations, 4 EC-IC bypasses and clip trappings, 2 internal carotid artery ligations [1 combined with clip wrapping], and 2 clip trappings). Six of 17 patients experienced intraoperative ruptures. There were no intraoperative ruptures among the bypass cases and 75% (3/4) of patients achieved a good neurologic outcome. Further, a literature review was performed to identify all previously reported cases of BAs undergoing clip ligation, clip wrapping, EC-IC bypass/clip trapping, and endovascular therapies, encompassing 246 BA cases across 33 studies. Intraoperative ruptures occurred in 29% of clip ligations (23/79), 27.2% of clip wrappings (6/35), 16.1% of EC-IC bypasses (5/31), and 0% of endovascular treatments. Aneurysm recurrence occurred in 2.97% (3/101) with endovascular therapies to 0% with EC-IC bypass. Mortality was 8.8% for clip ligation/wrapping (10/114), 6.5% for EC-IC bypass (2/31), and 4.0% for endovascular treatments (4/101). Endovascular interventions have a favorable procedural safety profile but high rates of retreatment for persistent filling or posttreatment aneurysmal growth. Clip ligation and clip wrapping techniques have lower retreatment rates but slightly higher intraoperative risk. EC-IC bypass can safely provide definitive aneurysm securement and should be considered as a first-line therapy for BAs at high-volume bypass centers.

Stent placement in patients with acute subarachnoid haemorrhage: when is it justified?

PurposeEndovascular stents are widely used for the elective treatment of cerebral aneurysms. Acute stenting is performed in the management of dissections, pseudo-aneurysms, broad-based aneurysms or as a ‘bail out’ measure after coil migration. The purpose of this study is to review the safety of using stents in acute subarachnoid haemorrhage.MethodsThe stent registry of our institution was reviewed for procedures in patients with acute subarachnoid haemorrhage. Imaging studies were reviewed on the hospital’s PACS system and the patients’ notes were retrieved to assess complications and clinical outcomes. Procedures were analysed according to the type of stent, treatment indication, antiplatelet regime, complications and outcomes.ResultsBetween 2008 and 2016, 51 stents were placed during 50 stenting procedures in 49 patients with acute subarachnoid haemorrhage. This included 24 patients with saccular aneurysms, 10 with blister aneurysms, 10 dissections and five fusiform aneurysms. Stents were deployed in ‘bail out’ situations on eight occasions. In six cases, flow-diverting stents were used. Eighteen patients (37%) in the cohort suffered a stroke. Nine patients (18%) suffered persistent clinical deficits as a result of the stenting procedure, all but one of which occurred within 24 h. Two patients had a transient ischaemic episode, and there was evidence of asymptomatic ischaemia on imaging in four cases (8%). Five patients died, three (6%) as a result of procedural complications. Twelve patients (25%) required a further embolisation procedure.ConclusionThe use of stents in acute subarachnoid haemorrhage incurs a considerable complication risk and should be reserved for exceptional circumstances.

Treatment of blood blister aneurysms of the internal carotid artery with flow diversion

BackgroundBlood blister aneurysms (BBA) are a rare subset of intracranial aneurysms that represent a therapeutic challenge from both a surgical and endovascular perspective.ObjectiveTo report multicenter experience with flow diversion exclusively...

Mid A1 blister aneurysm presenting with subarachnoid hemorrhage: Case report and review

Blister aneurysms are uncommon and difficult-to-treat lesions. They are a substantial cause of morbidity and mortality when encountered. Here, we report a blister aneurysm of the mid A1 segment of the anterior cerebral artery presenting with diffuse basal subarachnoid hemorrhage (SAH). The aneurysm was treated by surgical clipping of the parent vessel. Postoperatively, there was no filling of the parent vessel or aneurysm. A treatment algorithm including direct surgical repair and flow diversion for ruptured blister aneurysms is described. A high level of suspicion should be maintained in the setting of angiographic-negative SAH with an asymmetrically diffuse pattern.

Evaluation of Enterprise Stent-Assisted Coiling and Telescoping Stent Technique as Treatment of Supraclinoid Blister Aneurysms of the Internal Carotid Artery.

Supraclinoid blister aneurysms (BAs) of the internal carotid artery are uncommon and deadly, and appropriate treatment is controversial. Endovascular reconstruction may allow treatment through aneurysm isolation. We report a single-institution experience in the use of Enterprise stent-assisted coiling (ESAC) for treating BAs to appraise the safety and efficacy of this technique. Patients treated with ESAC for a BA at our institution between 2013 and 2016 were retrospectively included in this study. Patients' aneurysm characteristics, progression status, aneurysm occlusion on follow-up angiography, and modified Rankin Scale (mRS) score were recorded and analyzed. Occlusion rates and neurologic outcomes were compared between patients treated with a single stent and those treated with multiple telescoping stents. Forty-four patients were included (17 males; average age, 47.3 years), and ESAC was successfully performed in all patients. Immediate postprocedure angiography revealed complete occlusion in 23 patients (52.3%), residual neck in 15 (34.1%), and residual aneurysm in 6 (13.6%). Twenty patients (45.5%) suffered perioperative cerebral vasospasm, and 3 (6.8%) died of secondary ischemic stroke. The duration of follow-up ranged from 2.5 to 27 months (mean, 11.59 ± 5.76 months). One patient with recurrence was treated with additional coiling, and another patient was treated with a covered stent. The use of telescoping stents was associated with a better complete aneurysm occlusion rate compared with the use of single stents (84.4% [27 of 34] vs. 44.4% [4 of 9]; P= 0.04). Follow-up mRS score was ≤1 for 32 of 41 patients (78.4%). ESAC to treat BAs is safe, effective, and provides good clinical outcomes. ESAC with telescoping stents has a higher follow-up complete occlusion rate compared with ESAC with single stents.

Flow diverter treatment of cerebral blister aneurysms.

Blood blister-like aneurysms (BBA) are small, friable, broad-based aneurysms that represent high risk for rerupture. Treatment of BBA is challenging, and may include surgical wrapping, clipping, multiple overlapping stents, and/or coiling. Flow diversion is a rapidly evolving treatment strategy for intracranial aneurysms, but the evidence for its use in cases of BBA is scarce. A retrospective review of flow-diverter-treated, ruptured BBA cases at our tertiary care institution was undertaken. Clinical, imaging, procedural, and mid-term follow-up data on the patients were collected. Eight patients underwent flow-diverter stent treatment for ruptured BBA. Median age at time of treatment was 49years (interquartile range [IQR] 42-57) with five females (62.5%). The most common location of the BBA was the supraclinoid segment of the internal carotid artery. The median Hunt-Hess score was 2 (IQR 1.7-3.2). All patients were treated with dual anti-platelet therapy. Good clinical outcomes (modified Rankin score 0-2) were seen in 6/7 (85.7%) patients with available follow-up at 1year. Complete occlusion of the aneurysm on latest angiogram (7) or MRI (1) was seen in 6/8 (75%) patients (at a median of 8months). No patient had rerupture, retreatment, or recurrence of the aneurysm. Flow-diverter stents may be a feasible treatment option for BBAs. They offer high occlusion and low retreatment rates with good mid-term outcomes, but the long-term efficacy remains unknown. Also, dual anti-platelet therapy in the acute ruptured setting can be challenging.