Endovascular Treatment Strategy and Clinical Outcomes for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery Using Low-Profile Visualized Intraluminal Support Stent

Endovascular treatments of intracranial vertebral and internal carotid arteries dissections: An interactive systematic review and meta-analysis

INTRODUCTION

Management of intracranial artery dissection (IAD) remains elusive in medical practice. Intracranially, vertebral artery dissection (VAD) is more commonly encountered than internal carotid artery dissection (ICAD). Deconstructive (EVT-d) and reconstructive (EVT-r) endovascular techniques have been utilized to treat VAD and ICAD. This meta-analysis investigates the safety and efficacy of EVT-r and EVT-d in the management of VAD and ICAD.

METHODS

The literature was searched for all studies with consecutive patient series evaluating EVT-d or EVT-r for VAD or ICAD management. Baseline characteristics and outcomes were compared between EVT-r and EVT-d groups using the random-effect model and meta-regression approaches.

RESULTS

Overall, 1095 cases pooled from 56 studies were included. There was no statistically significant difference in baseline characteristics between VAD and ICAD. EVT-r was applied in 647 cases (59.1%) and EVT-d in the rest There was no statistical difference in the rate of procedural complications between EVT-r and EVT-d. Although EVT-d was significantly associated with higher rates of complete aneurysm occlusion (86.4%), lower rates of good clinical outcomes (72.1%) and higher mortality (15.1%) were achieved compared to EVT-r (70.2%, 83.3%, and 9.5%; respectively). The mortality rate was higher, and good clinical outcomes were less common in ruptured aneurysms. Ischemic presentation was statistically associated with poor outcomes (mRS 3-5) but low mortality. ICAD often tended to grow following treatment and resulted in poor neurological outcomes.

CONCLUSIONS

IAD has favorable outcomes when treated appropriately. Novel reconstructive endovascular techniques are promising and should be integrated well in endovascular practice. Further studies are warranted.

A Case of Ruptured Carotid Traumatic Blood Blister-like Aneurysm

Ruptured cerebral aneurysms that occur in the anterior wall of the internal carotid artery (ICA) are known as blood blister-like aneurysms (BBAs); they have been reported to account for 0.3% to 1% of all ruptured ICA aneurysms. In this report, we describe the treatment of an unusual traumatic BBA (tBBA) with high-flow bypass using a radial artery graft, which resulted in a favorable outcome. A 59-year-old female suffered from an acute epidural hematoma, traumatic subarachnoid hemorrhage, and traumatic carotid-cavernous sinus fistula (tCCF) after being involved in a motor vehicle accident. Her angiography results showed tCCF and a tBBA on the anterior wall of the right ICA. On the fourth day after injury, we found rebleeding from the tBBA and performed an emergency high-flow bypass using a radial artery graft with lesion trapping as a curative procedure for the tCCF and tBBA. Postoperatively, right abducens nerve palsy appeared, but no other neurological symptoms were noted; the patient was thereafter transferred to a rehabilitation hospital 49 days after injury. Traumatic ICA aneurysms commonly occur close to the anterior clinoid process, form within 1 to 2 weeks of injury, and often rupture around 2 weeks after trauma. This case was considered rare as the ICA was likely injured and bleeding at the time of injury, resulting in a form of tBBA; this allowed early detection and appropriate treatment that resulted in a good outcome.

Efficacy of Magnetic Resonance Contrast-Enhanced Vessel Wall Imaging as an Ancillary Examination for Subarachnoid Hemorrhage With Bleeding Points Difficult to Determine on Conventional Vascular Imaging: A Report of Three Cases

Here, we have demonstrated the efficacy of magnetic resonance contrast-enhanced vessel wall imaging (CE-VWI) as an ancillary examination for subarachnoid hemorrhage with bleeding points difficult to confirm by conventional vascular imaging. Case 1 had a ruptured small aneurysm with a size of 1.8 × 1.1 mm at the origin of left anterior choroidal artery. CE-VWI showed enhancement of the apex of the aneurysm. Surgical clipping was performed by a mini-clip. In Case 2, a ruptured small aneurysm, 2.1 × 1.9 mm, was detected at right middle cerebral artery bifurcation. CE-VWI showed enhancement of the aneurysmal wall. Endovascular coil embolization was performed. In Case 3, irregular dilatation of left internal carotid artery (ICA) was detected. CE-VWI demonstrated enhancement of the dilatation wall. The lesion was deemed to be a dissection of the ICA or a blood blister-like aneurysm. Endovascular treatment using intracranial stent placement was performed, and the patient has had no rebleeding events for one and a half years. In all cases, conventional vascular imaging detected scanty morphological changes, and CE-VWI information provided reliable confirmation of the lesions as bleeding points.

A Case of Ruptured Anterior Cerebral Artery Dissection Prevented from Re-rupture with Stenting and Modification of Antiplatelet Agents

A case of ruptured anterior cerebral artery (ACA) dissection was treated with multiple neck-bridge stents, with modification of antiplatelet administration according to changes in the shape of the aneurysm in the acute phase. A 67-year-old woman presented with severe subarachnoid hemorrhage and fusiform dilatation was observed in the left ACA between the A1 and A2 segments. The use of stents in the acute phase is associated with high risk of ischemic complications. Prasugrel administration, which is considered to have low drug resistance, may have allowed safe stent use in the acute phase.