The Efficacy of Endovascular Treatment of Ruptured Blood Blister-Like Aneurysms Using Stent-Assisted Coil Embolization

Abstract

<jats:p> We report our experience with endovascular treatment and follow-up results of a ruptured blood blister-like aneurysm (BBA) in the supraclinoid internal carotid artery. We performed a retrospective review of ruptured blood blister-like aneurysm patients over a 30-month period. Seven patients (men/women, 2/5; mean age, 45.6 years) with ruptured BBAs were included from two different institutions. The angiographic findings, treatment strategies, and the clinical (modified Rankin Scale) and angiographic outcomes were retrospectively analyzed. </jats:p><jats:p> All seven BBAs were located in the supraclinoid internal carotid artery. Four of them were ≥ 3 mm in largest diameter. Primary stent-assisted coiling was performed in six out of seven patients, and double stenting was done in one patient. In four patients, the coiling was augmented by overlapping stent insertion. Two patients experienced early re-hemorrhage, including one major fatal SAH. Complementary treatment was required in two patients, including coil embolization and covered-stent placement, respectively. Six of the seven BBAs showed complete or progressive occlusion at the time of late angiographic follow-up. The clinical midterm outcome was good (mRS scores, 0–1) in five patients. </jats:p><jats:p> Stent-assisted coiling of a ruptured BBA is technically challenging but can be done with good midterm results. However, as early regrowth/re-rupture remains a problem, repeated, short-term angiographic follow-up is required so that additional treatment can be performed as needed. </jats:p>

Endovascular management of intracranial blister aneurysms: spectrum and limitations of contemporary techniques

“…Several subsequent reports highlighted the pitfalls associated with primary coiling of blister aneurysms, including high rates of early aneurysmal regrowth 18 24 26–28 33. For example, Park et al 27 performed seven endovascular coiling procedures (4 conventional, 2 stent-assisted, and 1 balloon-assisted) in four patients with ruptured ICA blister aneurysms; all four patients experienced aneurysmal regrowth, resulting in two early aneurysmal re-ruptures.…”

Blister Aneurysms

“…2). Stent-assisted coiling has allowed a significantly larger proportion of blister aneurysms to be treated successfully with an endovascular approach, and good clinical outcomes have been reported in 62-89 % of patients [16,[40][41][42]. A majority of treated patients, however, still had to have more than one procedure, either for placement of a second stent within the first or placement of additional coils after aneurysm regrowth becomes evident on followup imaging [40,41].…”

“…A majority of treated patients, however, still had to have more than one procedure, either for placement of a second stent within the first or placement of additional coils after aneurysm regrowth becomes evident on followup imaging [40,41]. Early postoperative or perioperative hemorrhage, most often fatal, has also been reported to occur in 13-28 % of blister aneurysm patients treated using stent and coil techniques [16,41,42]. The results of initial attempts to utilize stents to augment endovascular treatment by endosaccular coiling were mixed.…”

Endovascular treatment of blister aneurysms

“…12 Between the 2 aforementioned studies and 2 separate studies including patients with ruptured blister aneurysms who underwent treatment predominantly with stent-assisted coil embolization, good clinical outcomes were reported, with modified Rankin Scale (mRS) scores of ≤ 2 in the vast majority of patients. 12,15,22,36 Despite the potential for good angiographic and clinical outcomes, actual use of stent-assisted embolization is limited based on technical factors, because many blister aneurysms have domes that are too small or too morphologically challenging to accommodate embolic material. Nonetheless, direct embolization techniques represent a conceivable endovascular option that offers immediate occlusion and, in the context of patients presenting with subarachnoid hemorrhage (SAH), the ability to secure the aneurysm with concomitant reduction in the potential for rerupture.…”

“…4), and primary coiling without any assistance is rare. 12,15,18,22,36,46,52 The use of a liquid embolic agent for treatment is exceedingly rare and has not been reported without the use of concomitant stenting.…”