Endovascular Patch Embolization for Blood Blister–Like Aneurysms in Dorsal Segment of Internal Carotid Artery

doi:10.1016/j.wneu.2018.01.014

World Neurosurgery

Volume 113, May 2018, Pages 26-32

https://doi.org/10.1016/j.wneu.2018.01.014 Get rights and content

Highlights

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The optimal treatment for blood blister–like aneurysms (BBAs) in the dorsal segment of the internal carotid artery is still controversial. Considering those special pathologic characteristics of BBAs, we developed a new technique for the effective treatment of BBAs, which could isolate the aneurysm and maintain an intact parent artery as well.
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On the basis of the traditional stent-assisted coil embolization, this method can anchor the coils inside the sac and around the neck of aneurysm. As a result, the coil combined with the stent can prevent the blood flow from the break point of the arterial wall.
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Furthermore, we illustrate the details of this technique with schematic diagrams and case in this manuscript, which can be understood easily.

Objective

Blood blister–like aneurysms (BBAs) in the dorsal segment of the internal carotid artery are fragile and difficult to treat, and the optimal treatment for BBAs is still controversial. We report clinical and angiographic results with procedural details for the treatment of BBA by using the endovascular patch embolization method.

Methods

We retrospectively reviewed patients who presented with subarachnoid hemorrhage caused by internal carotid artery–BBAs and were treated with the endovascular patch embolization method in our center from October 2011 to March 2015. Clinical records, angiographic findings, procedural details, and follow-up results are reported in this study.

Results

Eight patients were enrolled in this study. All patients were treated with the endovascular patch embolization method. The key points of this method are step-by-step stent deployment and swaying of the microcatheter to coil the aneurysm sac and the wedge-shaped space between the stent and parent artery and, thereby, in the aneurysm sac and parent artery around the aneurysm neck. When the stent is completely deployed, an endovascular patch is formed and anchored around the neck of the BBA. The procedure was successful in all cases. No acute complications developed in any case. No rerupture or recurrence of the BBA occurred during follow-up. One patient with Hunt-Hess V subarachnoid hemorrhage died of multiple organ failure 4 months post treatment. Another patient died of intracranial infection related to the ventricle-peritoneal shunt. The remaining 6 patients had good clinical outcomes (modified Rankin Scale score of zero).

Conclusion

Endovascular patch embolization is an improvement on stent-assisted coil embolization, which could be successfully performed only with extensive skill and patience. Endovascular patch embolization could be an effective method in BBA treatment. However, its efficacy and safety should be verified in a larger patient cohort and long-term follow-up study.

Introduction

Blood blister–like aneurysm (BBA) in the internal carotid artery (ICA) is a special type of ruptured aneurysm that originates from the dorsal segment of the ICA. It accounts for 0.9%–6.5% of all ICA aneurysms,1, 2 1% of all intracranial aneurysms,³ and 0.5%–2% of all ruptured intracranial aneurysms.4, 5 BBA is different from a true aneurysm, with the loss of not only the internal elastic lamina but also the vascular intima and media, leaving only a fragile fibrous layer.⁶ These special pathologic characteristics of BBAs lead to their rapid enlargement in a short time with a high risk of rerupture.

Many methods of BBA treatment are reported in the literature, but the optimal treatment for BBAs is still controversial.7, 8 Reconstructive treatment with stents and coils appears to be a viable option for BBAs.9, 10, 11 An endovascular patch embolization method was used to treat BBAs at our center to isolate the aneurysm and maintain an intact parent artery, and it was considered effective and safe.

Section snippets

Methods

This retrospective study was approved by local institutional review boards. We retrospectively reviewed patients who presented with subarachnoid hemorrhage (SAH) caused by a BBA in the dorsal segment of the ICA and were treated with the endovascular patch embolization method at our center from October 2011 to March 2015.

The diagnosis of ICA-BBA in our center was based on the following criteria: 1) in the dorsal, nonbranching site of the ICA; 2) small aneurysms (primary size usually <3 mm)

Results

We retrospectively analyzed the clinical data of 8 patients, which included 3 males and 5 females (age ranged from 30–60 years old; average 49.5 years old) who underwent endovascular patch embolization for ICA BBAs in our center from October 2011 to March 2015. Because most of these aneurysms were suspected BBAs in local hospitals and then transferred to our center for treatment, the hemorrhage-treatment time ranged from 1 day to 17 days. Among the 8 patients, the procedure was successfully

Current Treatment of BBA

Current treatment methods for BBA include surgical treatment and endovascular treatment. A systematic review of 311 cases of BBA revealed that there were various treatment options for BBAs. Furthermore, the rates of mortality, recovery, rehemorrhage, and aneurysm recurrence in patients after these different treatments were statistically analyzed, and they found that none of the surgical procedures was significantly better than endovascular treatment.¹²

Several types of endovascular treatment are

Conclusions

BBAs are a special type of aneurysm, and the hemodynamic impact and lack of support for the embolic content by the thin aneurysm wall contribute to the high risk of treatment. Current endovascular treatments mainly focus on guiding blood flow and reducing the impact on the embolic material in the aneurysm to the greatest extent; however, the techniques do not enhance the stability of the embolic material in the aneurysm. Our endovascular patch technique enables both blood flow guidance and

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Cited by (21)

Treatment of Traumatic Internal Carotid Artery Aneurysm by Flow-Diverter: A Single-Center Experience
2022, Neurochirurgie
Citation Excerpt :
Endovascular approaches have emerged as therapeutic alternatives [8,9,14,26]. Endovascular techniques are being used more frequently in the treatment of traumatic aneurysms because they involve less brain retraction and cerebral dissection and are more minimally invasive [9,24,26]. Horowitz et al. first described endovascular methods for the treatment of aneurysm in a 30-month-old child with traumatic basilar artery aneurysm after endoscopic third ventriculostomy [27].
Traumatic intracranial aneurysm (TICA) is a rare vascular lesion with various etiologies and a high mortality rate when diagnosed late. In this study, we present our cases of TICA, which we treated with flow-diverter stents due to different etiological factors.
Clinical data were recorded for 8 patients: age, gender, etiological factors, aneurysm location, aneurysm type, rupture, main artery status, and postoperative complications.
75% (n:6) of the patients were male and 25% (n:2) female. Etiologically, there was intracranial tumor surgery in 3 cases (37.5%), fall from height in 2 (25%), road accident in 2 (25%), and blunt trauma in 1 (12.5%). Reconstruction used a flow-diverting stent in all cases. One patient experienced intraoperative iatrogenic rupture of the distal arterioles due to a microwire. Mean angiographic follow-up was 17.8 months (range, 6-32 months). During follow-up, none of the patients required renewed endovascular treatment.
Traumatic aneurysm is a vascular lesion with high mortality when diagnosed late. In case of suspected vascular injury after trauma or intracranial surgery, further evaluation should be performed without delay. TICA can be safely treated with flow-diverter stents, conserving the main artery.
Comparison of Blister Aneurysm Treatment Techniques: A Systematic Review and Meta-Analysis
2021, World Neurosurgery
Blood blister aneurysms are small, thin-walled, rapidly growing side-wall aneurysms that have proved particularly difficult to treat, and evidence-based guidance for treatment strategies is lacking. A systematic review and meta-analysis was performed to aggregate the available data and compare the 3 primary treatment modalities.
We performed a comprehensive literature search according to PRISMA guidelines followed by an indirect meta-analysis that compares the safety and efficacy of surgical, flow-diverting stents (FDS), and other endovascular approaches for the treatment of ruptured blood blister aneurysms.
A total of 102 studies were included for quantitative synthesis, with sample sizes of 687 treated surgically, 704 treated endovascularly without FDS, and 125 treated via flow diversion. Comparatively, FDS achieved significantly reduced rates of perioperative retreatment compared with both surgical (P = 0.025) and non-FDS endovascular (P < 0.001). The FDS subgroup also achieved a significantly lower incidence of perioperative rebleed (P < 0.001), perioperative hydrocephalus (P = 0.012), postoperative infarction (P = 0.002), postoperative hydrocephalus (P < 0.001), and postoperative vasospasm (P = 0.002) compared with those patients in the open surgical subgroup. Although no significant differences were found among groups on the basis of functional outcomes, angiographic outcomes detailed by rates of radiographic complete occlusion were highest for surgical (90.7%, 262/289) and FDS (89.1%, 98/110) subgroups versus the non-FDS endovascular subgroup (82.7%, 268/324).
Flow diversion seems to be an effective treatment strategy for ruptured blood blister aneurysms, with lower rates of perioperative complications compared with surgical and other endovascular techniques, but studies investigating long-term outcomes after flow diversion warrant further study.
Treatment of traumatic intracranial aneurysm: Experiences at a single center
2020, Clinical Neurology and Neurosurgery
Citation Excerpt :
However, we should pay more attention to intraoperative or postoperative rupture when treating TICA that originates from the rupture of all arterial layers with perivascular hematoma formation and organization [13–15]. Postoperative rupture may happen more frequently with interventional embolization since the fragile fibrous layer in TICA cannot provide enough support to ensure the stability of the coils inside the aneurysm [16]. Therefore, special techniques have been developed to treat TICA.
To report the treatment and outcome of traumatic intracranial aneurysm (TICA) cases at the Southwest Hospital, Army Medical University in China.
All patients diagnosed with TICA at our institution from January 1, 1977, to October 31, 2018, and meeting the inclusion/exclusion criteria were included in the study. Cases were reported separately for those diagnosed before 1998 and those after 1998.
A total of 25 patients were included in the study. Ten were diagnosed with TICA prior to 1998. Seven of these 10 patients were treated surgically with parent artery sacrificed, including aneurysmectomy, trapping, and bypass. The mean Glasgow Outcome Scale (GOS) score for the 7 patients with surgical treatment was 3.1. Three of the 10 patients died of severe complications, including intracranial infection, delayed bleeding, and deadly injury. After 1998, 15 patients were diagnosed with TICA. Thirteen presented with head trauma and two with iatrogenic TICA following ventricle drainage or sphenoid ridge meningioma resection. Thirteen were treated with endovascular treatment, including coil alone, glue, coil-associated glue, stent alone, stent-assisted coil embolization, one with clipping, and one with conservative treatment. The 13 patients with endovascular treatment achieved a mean GOS score of 4.5. Among the 13 patients, one died from intracranial infection, one suffered recurrence, and one had intraoperative rupture.
Although the treatment of TICA has traditionally been surgical, endovascular treatment with different techniques, such as endovascular patch, provides a valuable alternative. Currently, the flow diverter is a popular embolization device and may represent another valid treatment option for TICA.
Letter to the Editor Regarding “Endovascular Patch Embolization for Blood Blister–Like Aneurysms in Dorsal Segment of Internal Carotid Artery”
2018, World Neurosurgery
Treatment with a flow diverter-assisted coil embolization for ruptured blood blister-like aneurysms of the internal carotid artery: a technical note and analysis of single-center experience with pooled data
2023, Neurosurgical Review
Advances in research on blood blister aneurysms
2023, Chinese Journal of Neurosurgery

View all citing articles on Scopus

: Conflict of interest statement: This work was supported by the National Key Research and Development Program (Grant 2016YFC1301800).

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Technical NoteEndovascular Patch Embolization for Blood Blister–Like Aneurysms in Dorsal Segment of Internal Carotid Artery

Highlights

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Current Treatment of BBA

Conclusions

Eur J Radiol

Clin Neurol Neurosurg

World Neurosurg

Internal carotid artery aneurysms, distal medial wall aneurysms of superior wall of internal carotid artery

Nationwide surveillance of IC anterior (or dorsal) wall aneurysm: with special reference to its dissecting nature

Acta Neurochir Suppl

Dorsal internal carotid artery aneurysms with special reference to angiographic presentation and surgical management

Acta Neurochir

Endovascular coil embolization for anterior choroidal artery aneurysms

Neuroradiology

Reconstructive endovascular treatment of ruptured blood blister-like aneurysms of the internal carotid artery

J Neurosurg

Pathological consideration of a “blister-like” aneurysm at the superior wall of the internal carotid artery: case report

Neurosurgery

Blister-like aneurysms of middle cerebral artery: a multicenter retrospective review of diagnosis and treatment in three patients

Neurosurg Rev

Reconstructive treatment of ruptured blood blister-like aneurysms with stent and coil

Neurosurgery

The efficacy of endovascular treatment of ruptured blood blister-like aneurysms using stent-assisted coil embolization

Interv Neuroradiol

Towards a new treatment paradigm for ruptured blood blister-like aneurysms of the internal carotid artery? A rapid systematic review

J Neurointerv Surg

Blood blister-like aneurysms of the internal carotid artery

J Neurosurg

Technical Note
Endovascular Patch Embolization for Blood Blister–Like Aneurysms in Dorsal Segment of Internal Carotid Artery