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Delayed Treatment (≥5 Days) by Flow Diversion of Ruptured Blister-Like Cerebral Aneurysms

Case Series of 8 Consecutive Patients

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Abstract

Background and Purpose

Ruptured blister-like aneurysms (BLAs) are challenging lesions to treat, without any consensus on their management. Few studies have evaluated the safety and effectiveness of flow diverter stents (FDS) for this indication, with promising results. The goal was to evaluate the safety and effectiveness of a delayed (≥5 days) flow diversion strategy for the treatment of ruptured intracranial BLAs.

Material and Methods

A monocentric retrospective analysis of a prospectively collected database of intracranial aneurysms was performed. Eight consecutive patients with 9 ruptured intracranial BLAs from November 2010 to June 2018 were included in the study. The BLA treatment with FDS was delayed from the rupture (minimum rupture to treatment delay = 5 days, mean = 16.9 ± 9.2 days). Procedure-related complications were systematically recorded. Rebleeding occurrences were systematically assessed. Long-term clinical and angiographic follow-ups were recorded.

Results

No procedure-related death was recorded. Neither early nor late rebleeding was observed and one (12.5%) major procedure-related complication occurred (ischemic stroke). Most of the patients (5/8; 62.5%) had an mRS <2 at discharge. The immediate periprocedural control angiogram showed a complete exclusion of the aneurysm in one patient (12.5%) but at follow-up (mean delay = 19.8 months) all patients had a complete aneurysm occlusion. All patients had a long-term mRS <2.

Conclusion

This case series suggests that a delayed treatment (≥5 days after the hemorrhagic event) of ruptured BLAs with FDS is feasible, and may be safe and effective in terms of rebleeding prevention and long-term angiographic outcome.

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Abbreviations

BA:

Basilar artery

BLA:

Blister-like aneurysm

CS:

Cekirge-Saatci grading scale

DSA:

Digital subtraction angiography

FDS:

Flow diverter stent

ICA:

Internal carotid artery

IV:

Intravenous

mRS:

Modified Rankin scale

OKM:

O’Kelly-Marotta grading scale

PACS:

Picture archiving and communication system

PCA:

Posterior cerebral artery

RR:

Raymond-Roy grading scale

TIA:

Transient ischemic attack

References

  1. Peschillo S, Cannizzaro D, Caporlingua A, Missori P. A systematic review and meta-analysis of treatment and outcome of blister-like aneurysms. AJNR Am J Neuroradiol. 2016;37:856–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Peschillo S, Missori P, Piano M, Cannizzaro D, Guidetti G, Santoro A, Cenzato M. Blister-like aneurysms of middle cerebral artery: a multicenter retrospective review of diagnosis and treatment in three patients. Neurosurg Rev. 2015;38:197–202. discussion 202–3.

    Article  PubMed  Google Scholar 

  3. Mizutani T, Miki Y, Kojima H, Suzuki H. Proposed classification of nonatherosclerotic cerebral fusiform and dissecting aneurysms. Neurosurgery. 1999;45:253–9. discussion 259–60.

    Article  CAS  PubMed  Google Scholar 

  4. McLaughlin N, Laroche M, Bojanowski MW. Blister-like aneurysms of the internal carotid artery—management considerations. Neurochirurgie. 2012;58:170–86.

    Article  CAS  PubMed  Google Scholar 

  5. Causin F, Pascarella R, Pavesi G, Marasco R, Zambon G, Battaglia R, Munari M. Acute endovascular treatment (< 48 hours) of uncoilable ruptured aneurysms at non-branching sites using silk flow-diverting devices. Interv Neuroradiol. 2011;17:357–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Meling TR. What are the treatment options for blister-like aneurysms? Neurosurg Rev. 2017;40:587–93.

    Article  PubMed  Google Scholar 

  7. Peschillo S, Miscusi M, Caporlingua A, Cannizzaro D, Santoro A, Delfini R, Guidetti G, Missori P. Blister-like aneurysms in atypical locations: a single-center experience and comprehensive literature review. World Neurosurg. 2015;84:1070–9.

    Article  PubMed  Google Scholar 

  8. Fang C, Tan HQ, Han HJ, Feng H, Xu JC, Yan S, Nie ZY, Jin LJ, Teng F. Endovascular isolation of intracranial blood blister-like aneurysms with Willis covered stent. J Neurointerv Surg. 2017;9:963–8.

    Article  PubMed  Google Scholar 

  9. Cerejo R, Bain M, John S, Hardman J, Moore N, Hussain MS, Toth G. Flow diverter treatment of cerebral blister aneurysms. Neuroradiology. 2017;59:1285–90.

    Article  PubMed  Google Scholar 

  10. Hao X, Li G, Ren J, Li J, He C, Zhang HQ. Endovascular patch embolization for blood blister-like aneurysms in the dorsal segment of the internal carotid artery. World Neurosurg. 2018;113:26-32.

    Article  PubMed  Google Scholar 

  11. Chan RSK, Mak CHK, Wong AKS, Chan KY, Leung KM. Use of the pipeline embolization device to treat recently ruptured dissecting cerebral aneurysms. Interv Neuroradiol. 2014;20:436–41.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Consoli A, Nappini S, Renieri L, Limbucci N, Ricciardi F, Mangiafico S. Treatment of two blood blister-like aneurysms with flow diverter stenting. J Neurointerv Surg. 2012;4:e4.

    Article  PubMed  Google Scholar 

  13. Aydin K, Arat A, Sencer S, Hakyemez B, Barburoglu M, Sencer A, İzgi N. Treatment of ruptured blood blister-like aneurysms with flow diverter SILK stents. J Neurointerv Surg. 2015;7:202–9.

    Article  PubMed  Google Scholar 

  14. Chalouhi N, Zanaty M, Tjoumakaris S, Gonzalez LF, Hasan D, Kung D, Rosenwasser RH, Jabbour P. Treatment of blister-like aneurysms with the pipeline embolization device. Neurosurgery. 2014;74:527–32. discussion 532.

    Article  PubMed  Google Scholar 

  15. Lang ST, Assis Z, Wong JH, Morrish W, Mitha AP. Rapid delayed growth of ruptured supraclinoid blister aneurysm after successful flow diverting stent treatment. BMJ Case Rep. 2016;2016. doi: 10.1136/bcr-2016-012506.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Fischer S, Perez MA, Kurre W, Albes G, Bäzner H, Henkes H. Pipeline embolization device for the treatment of intra- and extracranial fusiform and dissecting aneurysms: initial experience and long-term follow-up. Neurosurgery. 2014;75:364–74. discussion 374.

    Article  PubMed  Google Scholar 

  17. Luecking H, Engelhorn T, Lang S, Goelitz P, Kloska S, Roessler K, Doerfler A. FRED flow diverter: a study on safety and efficacy in a consecutive group of 50 patients. AJNR Am J Neuroradiol. 2017;38:596–602.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Linfante I, Mayich M, Sonig A, Fujimoto J, Siddiqui A, Dabus G. Flow diversion with Pipeline Embolic Device as treatment of subarachnoid hemorrhage secondary to blister aneurysms: dual-center experience and review of the literature. J Neurointerv Surg. 2017;9:29–33.

    Article  PubMed  Google Scholar 

  19. Yoon JW, Siddiqui AH, Dumont TM, Levy EI, Hopkins LN, Lanzino G, Lopes DK, Moftakhar R, Billingsley JT, Welch BG, Boulos AS, Yamamoto J, Tawk RG, Ringer AJ, Hanel RA; Endovascular Neurosurgery Research Group. Feasibility and safety of pipeline embolization device in patients with ruptured carotid blister aneurysms. Neurosurgery. 2014;75:419–29. discussion 429.

    Article  PubMed  Google Scholar 

  20. Hu YC, Chugh C, Mehta H, Stiefel MF. Early angiographic occlusion of ruptured blister aneurysms of the internal carotid artery using the Pipeline Embolization Device as a primary treatment option. J Neurointerv Surg. 2014;6:740–3.

    Article  PubMed  Google Scholar 

  21. Raymond J, Roy D. Safety and efficacy of endovascular treatment of acutely ruptured aneurysms. Neurosurgery. 1997;41:1235–46.

    Article  CAS  PubMed  Google Scholar 

  22. Roy D, Milot G, Raymond J. Endovascular treatment of unruptured aneurysms. Stroke. 2001;32:1998–2004.

    Article  CAS  PubMed  Google Scholar 

  23. O’Kelly CJ, Krings T, Fiorella D, Marotta TR. A novel grading scale for the angiographic assessment of intracranial aneurysms treated using flow diverting stents. Interv Neuroradiol. 2010;16:133–7.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Cekirge HS, Saatci I. A new aneurysm occlusion classification after the impact of flow modification. AJNR Am J Neuroradiol. 2016;37:19–24.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Peitz GW, Sy CA, Grandhi R. Endovascular treatment of blister aneurysms. Neurosurg Focus. 2017;42:E12.

    Article  PubMed  Google Scholar 

  26. Zhu D, Yan Y, Zhao P, Duan G, Zhao R, Liu J, Huang Q. Safety and efficacy of flow diverter treatment for blood blister-like aneurysm: a systematic review and meta-analysis. World Neurosurg. 2018;118:e79-86.

    Article  PubMed  Google Scholar 

  27. Mokin M, Chinea A, Primiani CT, Ren Z, Kan P, Srinivasan VM, Hanel R, Aguilar-Salinas P, Turk AS, Turner RD, Chaudry MI, Ringer AJ, Welch BG, Mendes Pereira V, Renieri L, Piano M, Elijovich L, Arthur AS, Cheema A, Lopes DK, Saied A, Baxter BW, Hawk H, Puri AS, Wakhloo AK, Shallwani H, Levy EI, Siddiqui AH, Dabus G, Linfante I. Treatment of blood blister aneurysms of the internal carotid artery with flow diversion. J Neurointerv Surg. 2018;10:1074-8.

    Article  PubMed  Google Scholar 

  28. Cagnazzo F, di Carlo DT, Cappucci M, Lefevre PH, Costalat V, Perrini P. Acutely ruptured intracranial aneurysms treated with flow-diverter stents: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2018;39:1669–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Rouchaud A, Brinjikji W, Cloft HJ, Kallmes DF. Endovascular treatment of ruptured blister-like aneurysms: a systematic review and meta-analysis with focus on deconstructive versus reconstructive and flow-diverter treatments. AJNR Am J Neuroradiol. 2015;36:2331–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Szmuda T, Sloniewski P, Waszak PM, Springer J, Szmuda M. Towards a new treatment paradigm for ruptured blood blister-like aneurysms of the internal carotid artery? A rapid systematic review. J Neurointerv Surg. 2016;8:488–94.

    Article  PubMed  Google Scholar 

  31. Shah SS, Gersey ZC, Nuh M, Ghonim HT, Elhammady MS, Peterson EC. Microsurgical versus endovascular interventions for blood-blister aneurysms of the internal carotid artery: systematic review of literature and meta-analysis on safety and efficacy. J Neurosurg. 2017;127:1361–73.

    Article  PubMed  Google Scholar 

  32. Fang YB, Li Q, Wu YN, Zhang Q, Yang PF, Zhao WY, Huang QH, Hong B, Xu Y, Liu JM. Overlapping stents for blood blister-like aneurysms of the internal carotid artery. Clin Neurol Neurosurg. 2014;123:34–9.

    Article  PubMed  Google Scholar 

  33. Damiano RJ, Tutino VM, Paliwal N, Ma D, Davies JM, Siddiqui AH, Meng H. Compacting a single flow diverter vs. overlapping flow diverters for intracranial aneurysm: a computational study. AJNR Am J Neuroradiol. 2017;38:603–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6:1–9.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Neuroradiology, Pitié-Salpêtrière Hospital, APHP, Paris, France

    Romain Capocci, Eimad Shotar, Claudia Rolla-Bigliani, Amira Al Raaisi, Nader Sourour & Frédéric Clarençon

  2. Sorbonne University. Pierre and Marie Curie, Paris, France

    Eimad Shotar, Arthur André, Vincent Degos & Frédéric Clarençon

  3. Department of Neuroradiology, Foch Hospital, Suresnes, France

    Federico Di Maria

  4. Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France

    Arthur André & Anne-Laure Boch

  5. Department of Neuro-Intensive Care, Pitié-Salpêtrière Hospital, Paris, France

    Jugurtha Mahtout & Vincent Degos

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  1. Romain Capocci
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Correspondence to Frédéric Clarençon.

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Conflict of interest

R. Capocci, E. Shotar, F. Di Maria, C. Rolla-Bigliani, A. Al Raaisi, A. André, J. Mahtout, A.-L. Boch, V. Degos, N. Sourour and F. Clarençon declare that they have no competing interests.

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Capocci, R., Shotar, E., Di Maria, F. et al. Delayed Treatment (≥5 Days) by Flow Diversion of Ruptured Blister-Like Cerebral Aneurysms. Clin Neuroradiol 30, 287–296 (2020). https://doi.org/10.1007/s00062-019-00758-4

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