Endovascular exclusion of the anterior communicating artery with flow-diverter stents as an emergency treatment for blister-like intracranial aneurysms. A case report

Abstract

Blood blister-like aneurysms (BLAs) are rare lesions, associated with diffuse subarachnoid hemorrhage (SAH). BLAs tend to rebleed quickly after first bleeding and must be treated as an emergency. Acute treatment is challenging using surgical and endovascular approaches due to the fragile aneurysm wall and small sac. Flow-diverter stents (FDSs) may offer a new option for the treatment of difficult small aneurysms. We describe a case of a ruptured BLA on the anterior communicating artery (AComA) treated in the acute phase of SAH by endovascular exclusion of the AComA with deployment of two FDSs in the A1/A2 junctions of both anterior cerebral arteries (ACAs). A 61-year-old man was admitted for diffuse SAH with a focal interhemispheric hematoma. Angiography revealed multiple arterial wall irregularities on the AComA and both ACAs. We performed an endovascular shunt of the AComA by deploying two FDSs in both A1/A2 junctions. Immediate control injections confirmed flow diversion in the A1/A2 segments of the ACAs with decreased blood flow in the AComA. The patient's course in hospital was uneventful. A three-month follow-up angiogram confirmed complete exclusion of the aneurysms, complete exclusion of the AComA, and patency of the two ACAs without any persistent arterial wall irregularity. Endovascular bypass using an FDS for a ruptured BLA has never been described. It establishes a new therapeutic option despite the need for antiplatelet therapy. Endovascular AComA exclusion using an FDS may be a solution when no other treatment is available for a ruptured BLA.

Keywords: blister-like aneurysm; flow-diverter stent; subarachnoid hemorrhage.

Figure 1

A) Initial non-contrast computed tomography (CT) scan on presentation, showing diffuse subarachnoid hemorrhage with anterior interhemispheric hematoma (arrow). B) CT angiography axial reformatted image showing no aneurysm.

Figure 2

Three-dimensional digital subtraction angiography of the left internal carotid artery showing multiple irregularities (arrows) on the anterior communicating artery and on the A1/A2 junctions on both right and left sides.

Figure 3

A) Postprocedural flat-panel CT scan showing the implantation of the two flow diverter stents (FDSs) in the A1/A2 segments of both right and left anterior cerebral arteries. B) High dose flat panel CT scan showing both FDSs. C) X-ray single shot showing both FDSs.

Figure 4

Postoperative digital subtraction angiography in the anteroposterior projection showing the flow competition in the anterior communicating artery (AComA). A) No filling of the AComA by the right internal carotid artery (*). B) Persistence of low flow in the AComA by the left internal carotid artery (arrow).

Figure 5

Postoperative magnetic resonance imaging scan showing no ischemic lesion in the shunted territories of the anterior communicating artery. A) DWI. B) FLAIR. C) Gadolinium-enhanced T1. D) T2.

Figure 6

Six-month control digital subtraction angiography demonstrating total exclusion of the anterior communicating artery (*) and persistent flow in both anterior cerebral arteries. A) Anteroposterior projection of the right internal carotid artery. B) Anteroposterior projection of the left internal carotid artery. C) Oblique projection of the right internal carotid artery. D) Oblique projection of the left internal carotid artery.