Endovascular Exclusion of the Anterior Communicating Artery with Flow-Diverter Stents as an Emergency Treatment for Blister-Like Intracranial Aneurysms

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

Get full access to this article

View all access options for this article.

References

Ezaki

Takahata

Kamada

. Aneurysmal embolization of a blisterlike aneurysm of the internal carotid artery: a case report and review of the literature. Surg Neurol. 2006; 65 (6): 628–630; discussion 630.

Park

Han

. Endovascular treatment of blood blister-like aneurysms of the internal carotid artery. J Neurosurg. 2007; 106 (5): 812–819.

Meling

Sorteberg

Bakke

. Blood blisterlike aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: treatment and outcome. J Neurosurg. 2008; 108 (4): 662–671.

Lee

Kim

Park

. Reconstructive endovascular treatment of ruptured blood blister-like aneurysms of the internal carotid artery. J Neurosurg. 2009; 110 (3):431–436.

Lee

Choi

Jung

. Surgical strategies for ruptured blister-like aneurysms arising from the internal carotid artery: a clinical analysis of 18 consecutive patients. Acta Neurochir (Wien). 2009; 151 (2): 125–130.

Morris

Brophy

. Blister-like aneurysm of the anterior communicating artery. J Clin Neurosci. 2009; 16 (8): 1098–1100.

Nakiri

Al-Khawaldeh

Parente

. Treatment of ruptured intra-cranial internal carotid artery dissection using a flow-diverter stent. J Neuroradiol. 2012; 39 (4): 271–275.

Princiotta

Dall'Olio

Cirillo

. Staged treatment of a blood blister-like aneurysm with stent-assisted coiling followed by flow diverter in-stent insertion. A case report. Interv Neuroradiol. 2011; 17 (3): 365–370.

Consoli

Nappini

Renieri

. Treatment of two blood blister-like aneurysms with flow diverter stenting. J Neurointerv Surg. 2012; 4 (3): e4.

10.

Fiorella

Thiabolt

Albuquerque

. Antiplatelet therapy in neuroendovascular therapeutics. Neurosurg Clin N Am. 2005; 16 (3): 517–540, vi.

11.

Gaughen

Jr Raghavan

Jensen

. Utility of CT angiography in the identification and characterization of supraclinoid internal carotid artery blister aneurysms. Am J Neuroradiol. 2010; 31 (4): 640–644.

12.

Lee

Hsieh

Wang

. Ruptured symptomatic internal carotid artery dorsal wall aneurysm with rapid configurational change. Clinical experience and management outcome: an original article. Eur J Neurol. 2010; 17 (10): 1277–1284.

13.

Chung

Shin

Lim

. Ideal Internal Carotid Artery Trapping Technique without Bypass in a Patient with Insufficient Collateral Flow. J Korean Neurosurg Soc. 2009; 45 (4): 260–263.

14.

Kamijo

Matsui

. Acute extracranial-intracranial bypass using a radial artery graft along with trapping of a ruptured blood blister-like aneurysm of the internal carotid artery. Clinical article. J Neurosurg. 2010; 113 (4): 781–785.

15.

Kawashima

Okada

Kawamata

. Successful treatment of a blood blister-like aneurysm of the internal carotid artery by trapping with a high-flow bypass. J Clin Neurosci. 2008; 15 (7): 797–800.

16.

Ahn

Cho

Jung

. Blister-like aneurysms of the supraclinoid internal carotid artery: challenging endovascular treatment with stent-assisted coiling. J Clin Neurosci. 2008; 15 (9): 1058–1061.

17.

Islam

Manabe

Hasegawa

. Successful staged treatment for ruptured blister-like dissecting aneurysm of the intracranial internal carotid artery: acute GDC embolization for the blister-like aneurysm followed by proximal occlusion with extracranial-intracranial bypass in the chronic stage. Minim Invasive Neurosurg. 2004; 47 (3): 165–168.

18.

Korja

Rautio

Valtonen

. Primary treatment of ruptured blood blister-like aneurysms with stent-assisted coil embolization: report of two cases. Acta Radiol. 2008; 49 (2): 180–183.

19.

Piotin

Blanc

Spelle

. Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke. 2010; 41 (1): 110–115.

20.

Kulcsar

Houdart

Bonafe

. Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment. Am J Neuroradiol. 2011; 32 (1): 20–25.

21.

Martin

Cruz

Matouk

. The pipeline flow-diverting stent for exclusion of ruptured intracranial aneurysms with difficult morphologies. Neurosurgery. 2012; 70 (1 Suppl Operative): 21–28; discussion 28.

22.

Narata

Yilmaz

Schaller

. Flow-diverting stent for ruptured intracranial dissecting aneurysm of vertebral artery. Neurosurgery. 2012; 70 (4): 982–988; discussion 988–989.

23.

Pistocchi

Blanc

Bartolini

. Flow diverters at and beyond the level of the circle of Willis for the treatment of intracranial aneurysms. Stroke. 2012; 43 (4): 1032–1038.

24.

Rasskazoff

Silvaggio

Brouwer

. Endovascular treatment of a ruptured blood blister-like aneurysm with a flow-diverting stent. Interv Neuroradiol. 2010; 16 (3):255–258.

25.

Zeleňák

Zeleňáková

DeRiggo

. Flow changes after endovascular treatment of a wide-neck anterior communicating artery aneurysm by using X-configured kissing stents (cross-kissing stents) technique. Cardiovasc Intervent Radiol. 2011; 34 (6): 1308–1311.

26.

Fiorella

Lylyk

Szikora

. Curative cerebrovascular reconstruction with the Pipeline embolization device: the emergence of definitive endovascular therapy for intracranial aneurysms. J Neurointerv Surg. 2009; 1 (1): 56–65.