Endovascular treatment of blister aneurysms

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.

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“…Later, these patients were treated with flow-diverting stents without additional coil placement [10, 11]. …”

Section: Discussionmentioning

confidence: 99%

“…Patients with blister aneurysms were treated with single or double stenting at the start of the study period, using conventional stents [ 9 ]. Later, these patients were treated with flow-diverting stents without additional coil placement [ 10 , 11 ].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2018

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“…Blister aneurysms are rare vascular lesions. The most common localization of these aneurysms is supraclinoid with a proportion of 0.3%–1.7% of all aneurysms and up to 6.6% of aneurysmal ruptures [ 9 ]. Blister aneurysms have a higher risk of complications, such as rebleeding or even mortality [ 10 ].…”

Section: Discussionmentioning

confidence: 99%

Ventriculopleural shunt dysfunction as the first sign of a hidden aneurysmal Subarachnoid Hemorrhage: A case report

Vega-Moreno

Córdoba-Mosqueda

Aguilar-Calderón

et al. 2020

Annals of Medicine and Surgery

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Introduction Subarachnoid Hemorrhage (SAH) is caused by an aneurysmatic origin in 80% of cases. In the adult population, the risk of shunt dysfunction is about 16% in the first year, with proximal mechanical obstruction being the most frequent cause. Case report An 81-year-old man with a history of shunt system placement presented among clinical data of shunt dysfunction. The brain Computed Tomography (CT) showed dilation of the ventricular system, with no other associated injury. The cause of the dysfunction was a SAH determined by a lumbar puncture (LP) study. We performed an angiography reporting 3 aneurysms. Discussion The risk of shunt dysfunction at one year is 40% and at two years, the risk ups to 53% with obstruction of the system and infection being the two principal causes. The usefulness of a lumbar puncture for late detection of SAH lies in the red cells in the Cerebrospinal Fluid (CSF). When the CT is negative and the clinical suspicion remains, the lumbar puncture (LP) continues with higher sensitivity despite is over 12 hours of the onset clinic symptoms. Conclusion This case encourages to follow a rigorous protocol study for patients with multiple shunt dysfunction and chronic hydrocephalus. Also, this case invites to consider a hidden SAH secondary to a vascular pathology as a differential diagnosis for a multiple shunt dysfunction.

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“…10,11 Unruptured DAs are associated with stroke due to significant arterial stenosis, occlusion or pseudoaneurysm formation with subsequent haemodynamic and embolic infarcts or complications from mass effect; moreover, BAs and DAs are prone to rupture. 2,12 Open surgical techniques carry a high risk of morbidity and mortality, predominantly due to intraoperative rupture due to the fragility of the parent vessel wall. 7,8,13 In particular, the fusiform morphology in DAs and lack of a defined neck in BAs makes conventional endovascular techniques and surgical clipping impossible or inadequate in many cases.…”

Section: Discussionmentioning

confidence: 99%

“…[21][22][23] The reason why treatment of acutely ruptured BAs and DAs even with stents as monotherapy is effective can be explained by the findings of experimental studies that have demonstrated haemodynamic changes by stents. 12,20 Stents induce decrease of wall shear stress, inflow momentum, velocity and vorticity, and this might prevent aneurysmal rupture. Increased intraaneurysmal blood turnover time by diverting blood flow from the aneurysm and by dispersing the inflow into the aneurysm might promote thrombosis.…”

Section: Discussionmentioning

confidence: 99%

Endovascular treatment of intracranial ‘blister’ and dissecting aneurysms

et al. 2019

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IntroductionBlister and dissecting aneurysms may have a different pathological background but they are commonly defined by instability of the vessel wall and bear a high risk of fatal rupture and rerupture. Lack of aneurysm sack makes treatment challenging.PurposeThe purpose of this study was to assess the safety and feasibility of endovascular treatment of intracranial blister and dissecting aneurysms.MethodsWe retrospectively analysed all patients with ruptured and unruptured blister and dissecting aneurysms treated endovascularly between 2004–2018. Procedural details, complications, morbidity/mortality, clinical favourable outcome (modified Rankin Scale ≤2) and aneurysm occlusion rates were assessed.ResultsThirty-four patients with endovascular treatment of 35 aneurysms (26 dissecting aneurysms and 9 blister aneurysms) were included. Five aneurysms were treated by parent vessel occlusion, and 30 aneurysms were treated by vessel reconstruction using stent monotherapy ( n = 9), stent-assisted coiling ( n = 7), flow diverting stents ( n = 13) and coiling + Onyx embolization ( n = 1). No aneurysm rebleeding and no procedure-related major complications or deaths occurred. There were five deaths in consequence of initial subarachnoid haemorrhage. Complete occlusion (79.2%) was detected in 19/24 aneurysms available for angiographic follow-up, and aneurysm recurrence in 2/24 (8.3%). The modified Rankin Scale ≤2 rate at mean follow-up of 15.1 months was 64.7%.ConclusionTreatment of blister and dissecting aneurysms developed from coil embolization to flow diversion with multiple stents to the usage of flow diverting stents. Results using modern flow diverting stents encourage us to effectively treat this aneurysm entity endovascularly by vessel reconstruction. Therefore, we recommend preference of vessel reconstructive techniques to parent vessel occlusion.

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Endovascular treatment of blister aneurysms

Cited by 50 publications

References 54 publications

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

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

Ventriculopleural shunt dysfunction as the first sign of a hidden aneurysmal Subarachnoid Hemorrhage: A case report

Endovascular treatment of intracranial ‘blister’ and dissecting aneurysms

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