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

Abstract

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. 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. Stent-assisted coiling of a ruptured BBA is technically challenging but can be done with good midterm results. However, as early re-growth/re-rupture remains a problem, repeated, short-term angiographic follow-up is required so that additional treatment can be performed as needed.

Figure 1

A 39-year-old woman (patient No. 1) presenting with HH grade III SAH. A) Preprocedural DSA shows a blister aneurysm along the medial wall of the supraclinoid segment of the left ICA. B) Subsequent DSA shows enlargement of the blister aneurysm 4 days later. C) The patient was treated with stent-assisted coiling and followed by the stent-within-a-stent technique. D) Final DSA shows complete occlusion of BBA.

Figure 2

A 43-year-old woman (patient No. 7) presenting with HH grade II SAH. A) Initial angiogram shows a broad-based, shallow outpouching arising from a non-branching site along the anterior wall of supraclinoid ICA. B) Stent-assisted coil embolization with a single coil and followed by the stent-within-a-stent technique was performed. The angiogram revealed residual aneurysmal filling. C) Follow-up right ICA angiogram obtained 15 days postoperatively revealed considerable BBA growth. D) After re-treatment using stent-assisted coiling with multiple coils, the angiogram reveals minimal residual aneurysm filling of the aneurysm sac. E) At three months' angiographic follow-up examination, complete occlusion with reconstruction of the ICA was noted.

Figure 2

A 43-year-old woman (patient No. 7) presenting with HH grade II SAH. A) Initial angiogram shows a broad-based, shallow outpouching arising from a non-branching site along the anterior wall of supraclinoid ICA. B) Stent-assisted coil embolization with a single coil and followed by the stent-within-a-stent technique was performed. The angiogram revealed residual aneurysmal filling. C) Follow-up right ICA angiogram obtained 15 days postoperatively revealed considerable BBA growth. D) After re-treatment using stent-assisted coiling with multiple coils, the angiogram reveals minimal residual aneurysm filling of the aneurysm sac. E) At three months' angiographic follow-up examination, complete occlusion with reconstruction of the ICA was noted.

Figure 3

A 52-year-old man (patient No. 3) presenting with HH grade IV SAH. A) Preprocedural DSA shows a blister aneurysm along the lateral wall of the supraclinoid segment of left ICA. B) A control angiogram obtained after stent-assisted coil embolization, revealed minimal residual aneurismal filling. C) Follow-up left ICA angiogram obtained 12 days postoperatively revealed considerable BBA growth. D) Immediately after re-treatment with a covered stent, the control angiogram revealed subtle contrast media leakage into the recurred sac (arrow).