Blood blister-like aneurysm with rupture point close to origin of anterior choroidal artery

Endovascular treatment of intracranial blood blister-like aneurysms with the Willis covered stent: a case series

BACKGROUND AND PURPOSE

To evaluate the safety, feasibility, and effectiveness of the Willis covered stent (WCS) in treating blood blister-like aneurysms (BBAs).

MATERIALS AND METHODS

Twenty-one consecutive patients with BBAs treated with the WCS were identified between July 2017 and July 2022. The demographic, clinical, and angiographic data and procedural-related complications were collected from the medical records and the operative reports.

RESULTS

The present study included six men and fifteen women, with a mean age of 51.6 years (31-70 years). The immediate postoperative angiography demonstrated that the complete occlusion rate was 100%, with no endoleak. Ophthalmic artery (OA) occlusion occurred in five patients (23.8%). One patient developed delayed stent thrombosis on the third postoperative day. The mean angiographic follow-up time was 9.2 months (range 3-21 months). All twenty-one BBAs were occluded entirely, and the patency of the parent arteries was preserved. No aneurysm rupture or recurrence was found, and no retreatment was needed. Two patients developed mild to moderate asymptomatic in-stent stenosis. The clinical follow-up time was 20.0 months (range 15-33 months). Twenty patients had an mRS score of zero, and one had an mRS score of one.

CONCLUSIONS

Our series indicates that treating BBAs with WCSs was relatively safe and efficacious. However, the incidence of stent delivery failure and complications should not be neglected.

Long-term follow up of surgical management of blood blister-like aneurysms at non-branching sites of the internal carotid artery

To describe long-term follow-up of 25 patients who presented with subarachnoid hemorrhages due to blood blister-like aneurysms (BBAs) treated with direct clipping or clip reinforcement with or without direct neck repair. Between June 1993 and July 2009, 25 consecutive patients with ruptured BBAs of the supraclinoid internal carotid artery were retrospectively reviewed. The mean age of patients was 39.5 ± 11.3 years. The mean duration of clinical follow-up was 128.9 months (range, 85-196 months). All aneurysms were located in the supraclinoid portion of the internal carotid artery. The mean aneurysm diameter was 4.04 ± 1.3 mm on intra-operative microscopic field. Tearing of the aneurysmal neck during dissection occurred in 8 (32%) patients. Six of 7 patients with neck tearing underwent direct neck repair. Surgeons treated aneurysms via direct clipping with a Bemsheet® in 5 (20%) patients or by clip reinforcement with a silicone sheet in 20 (80%) patients. Clinical outcomes were favorable (modified Rankin Scale [mRS]: 0-2) in 21 (84%) of 25 patients. Four (16%) patients had an unfavorable outcome (mRS: 3-6). The patient with severe disability (mRS: 4) was treated with clip reinforcement and direct neck repair. Mild stenosis, moderate stenosis, and total occlusion of the parent artery were confirmed in 10 (40%) patients, 6 (24%) patients, and 1 (4%) patient, respectively. Although surgical treatment of BBAs was associated with varying degrees of parent vessel patency loss, long-term follow-up results for more than 10 years showed that direct surgical clipping or clip reinforcement with a silicone sheet appeared to be a curative surgery.

Flow Diverter Device-Assisted Coiling Treatment for Cerebral Blister Aneurysm: A Single-Center Study

Although endovascular treatment is a promising approach, blood blister-like aneurysms (BBAs) still present treatment challenges. This study aimed to assess the effectiveness and safety of flow diverter device-assisted coiling (FDDAC) for the treatment of BBAs, which are broad based and friable with a high rebleeding risk. Eight patients (five females and three males) who presented with subarachnoid hemorrhages (SAH) due to BBA ruptures between May 2020 and May 2022 were retrospectively enrolled. All patients were treated by flow diverter device (Tubridge) adjunctive coil embolization using a semi-deploying technique. The demographic information, angiographic data, interval between admission and treatment, materials, therapy, clinical outcomes (including periprocedural and intraprocedural mortality and morbidity), and follow-up results of all patients were reviewed. The mean age of the patients with BBAs was 48.5 years (range 31–62 years); aneurysm sizes ranged from 2.2 × 1.7 mm to 4.6 × 3.2 mm, and the median Hunt–Hess score was 3. All aneurysms were completely closed at follow-up, and all 8 patients had excellent clinical outcomes (modified Rankin scores = 0–2) at discharge. Angiograms showed complete aneurysm occlusion after 6 months to 1 year. In addition, there were no cases of re-rupture, re-treatment, or recurrence of the aneurysms. FDDAC is safe to use in patients with BBAs and provides an alternative treatment option for this disease.

Application of the Willis covered stent in the treatment of internal carotid artery blood blister-like aneurysms

The optimal treatment for blood blister-like aneurysm (BBA) has not yet been determined, and BBA has a high recurrence rate after stent-assisted embolization. The purpose of the present study was to evaluate the safety and feasibility of patients with BBA rupture in the acute phase or patients with BBA who have recurrence after stent-assisted coil embolization. Eight patients (8 women, mean age 50.3 ± 3.7 years) who presented with ruptured BBA or recurrence BBA that had been treated by stent-assisted embolization (5 patients after primary treatment of stent-assisted embolization) were retrospectively reviewed. Clinical follow-up was performed at 1 year after endovascular treatment. All patients were successfully treated with the WCS, and immediate postoperative angiography showed that the aneurysms were completely isolated. The ophthalmic artery was covered by WCS in one patient; however, this patient did not show any clinical visual field or vision symptoms. Procedure-related complications such as aneurysm rupture, vasospasm, acute thrombosis, or thromboembolism did not occur in any case. All patients were followed up for 1 year after endovascular treatment, and they were in good condition without recurrence. One patient developed delayed bleeding at the right temporal lobe. All patients had good clinical prognosis (modified Rankin Scale score ≤ 2). WCS implantation may be a safe and feasible strategy for patients with BBA rupture in the acute phase and patients with BBA who have recurrence after stent-assisted coil embolization and is a promising option worth exploring.

Lesion Trapping with High-Flow Bypass for Ruptured Internal Carotid Artery Blood Blister-Like Aneurysm Has Little Impact on the Anterior Choroidal Artery Flow: Case Series and Literature Review

OBJECTIVE

To examine the relationship between trap location and cerebral infarction in the anterior choroidal artery (AChA) region and associated risks in ruptured internal carotid artery blood blister-like aneurysm (BLA) treatment with high-flow bypass and lesion trapping.

METHODS

We included 26 patients diagnosed with BLAs and treated with high-flow bypass and trapping. We examined clinical characteristics including age, aneurysm trap location, final prognosis, cerebral infarction on postoperative magnetic resonance imaging, and modified Rankin Scale score at discharge. We also searched the literature for similar studies.

RESULTS

The modified Rankin Scale score at discharge was 0-2 in 20 patients, 3-5 in 2 patients, and 6 in 2 patients. In 19/26 patients (73.1%), the trapped segment was between the posterior communicating (PcomA) and the ophthalmic arteries. In 2 patients (7.7%), the trapped segment included the PcomA and the AChA; in 4 patients (15.4%), the trapped segment was within the PcomA. In these patients, the PcomA was occluded, and blood from the high-flow bypass flowed out to the AChA alone. No patient showed cerebral infarction. Our systematic review identified 70 patients. Of all 96 patients, 12 had AChA cerebral infarction; however, the infarction affected the prognosis of only 2 patients.

CONCLUSIONS

When treating BLAs with high-flow bypass and lesion trapping, the frequency of AChA cerebral infarction is low even when the PcomA is occluded, leaving the AChA as the only outflow vessel during high-flow bypass. However, PcomA occlusion may be associated with risks when treating patients with advanced arteriosclerosis near C1-2.

Supraclinoid internal carotid artery blister-like aneurysms: hypothesized pathogenesis and microsurgical clipping outcomes

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.

Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results

Background

We have been performing the clipping on crossed wrapping (COCW) method using 2 strips of cotton on patients with an internal carotid artery blood blister-like aneurysm (IC-BLA). This method is reliable in preventing the clips from slipping off and the aneurysm walls from being damaged during clipping, and it enables more appropriate and safer clipping. Here we report the technical details of this method and the long-term outcomes of patients receiving this procedure.

Methods

Fifteen of 1275 (1.5%) patients with a ruptured cerebral aneurysm who received treatment at the Saiseikai Kumamoto Hospital during the period from January 1, 1999, to December 31, 2016, had an IC-BLA. All 15 patients were treated with COCW, except for the first patient, who was treated using a single strip of cotton. The long-term outcome of the treatment was analyzed.

Results

The mean follow-up period was 74 months. The first patient experienced rerupture of an aneurysm 10 days after the operation. No complications or regrowth of an aneurysm were observed in the remaining 14 patients during the follow-up period, except for 1 patient who received a reoperation for the regrowth of an aneurysm. As the final outcome, the numbers of patients with a Modified Rankin Score of 0, 3, and 6 were 13, 1, and 1, respectively.

Conclusions

It is suggested that COCW is a treatment that enables safe and long-term management of lesions in IC-BLAs.

A Case of Ruptured Blood Blister-like Aneurysm Treated with Pipeline Embolization Device: Clinical Significance of Fetal-type Posterior Communicating Artery

Blood-blister like aneurysms (BBAs) are challenging lesions because of their wide fragile neck. Flow-diverting stents (FDSs), such as the Pipeline Embolization Device (PED), have been applied to treat BBAs less amenable to more established techniques of treatment. However, the use of FDSs, including the PED, in acute subarachnoid hemorrhage (SAH) still remains controversial. We report a case of aneurysm regrowth following PED application for a ruptured BBA that overlapped the origin of the dominant posterior communicating artery (PCoA), which was successfully treated after coil trapping of the origin of the fetal-type PCoA. And, we discuss the clinical significance of the fetal-type PCoA communicating with a BBA in terms of PED failure.

Current status of the treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery: A review

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.

Endovascular isolation of intracranial blood blister-like aneurysms with Willis covered stent

Objective

Intracranial blood blister-like aneurysm (BBA) is a rare type of aneurysm that lacks all layers of the arterial wall. These fragile aneurysms have the propensity to rupture with minimal manipulation, which makes them hazardous and difficult to treat. The present study evaluated the safety and feasibility of endovascular treatment of BBAs with the Willis covered stent.

Materials

Thirteen patients (7 men and 6 women, age range 28–68 years) who presented with ruptured BBAs and were treated with the Willis covered stent were retrospectively reviewed. Results of the procedures and treatment-related complications were recorded. Angiographic and clinical follow-ups were performed 4–6 months after the procedure.

Results

Placement of the covered stent was successful in all patients. Immediate angiography showed complete aneurysm occlusion in 12 patients while one patient showed a mild endoleak. This high rate of aneurysm exclusion ensured the security of postoperative antiplatelet treatment. Occlusion of the ophthalmic artery occurred in two patients and occlusion of the anterior choroidal artery occurred in one patient; however, none of them showed acute or delayed clinical symptoms. Thrombosis, aneurysm rupture, and other complications did not develop in any case. Angiographic follow-up showed complete aneurysm exclusion without aneurysm recurrence in any patients. Only two patients showed asymptomatic mild to moderate in-stent stenosis. All patients had satisfactory clinical outcomes (modified Rankin Scale score ≤1).

Conclusions

Willis covered stent implementation may be safe and feasible for BBAs. This strategy might be a promising option for this high-risk type of aneurysm.