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blister_aneurysm

Blister aneurysm

Blister aneurysms are elusive and technically challenging rare lesions characterized by a hemispherical shape and fragile arterial walls for surgery and endovascular treatment.

These fragile broad-based aneurysms have a propensity to rupture with minimal manipulation during surgical or endovascular explorations because, unlike saccular aneurysms, they lack all layers of the arterial wall. Aneurysm trapping with Extra intracranial bypass surgery is a safe and durable treatment 1).

Outcome

His grim prognosis is based on results that indiscriminately group all blister aneurysms together without taking into account the heterogeneous appearance of these lesions.

Treatment

Owing to their peculiar features and rare occurrence, ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery are challenging by both surgical and endovascular approaches and their proper management is uncertain.

Szumuda et al aimed to define the currently optimal treatment of ruptured BBAs in terms of mortality, outcome, rebleeding, and recurrence.

An in-depth search of electronic databases, gray literature and internet resources for ruptured BBAs was performed and complemented by data retrieval during neurosurgical congresses. Clinical and radiological characteristics, intervention details, outcomes, and the impact factor of the source journal were pooled.

The pooled cohort comprised 311 patients. Neither surgical nor endovascular methods had an impact on clinical outcome, aneurysm regrowth, remote bleeding, or complication rate. By contrast, aneurysm clipping was a predictor of intraoperative bleeding (OR 6.5; 95% CI 1.2 to 34.3), and stent-assisted coiling increased the likelihood of a second treatment (OR 4.1; 95% CI 1.3 to 13.1), its conversion to another modality (OR 4.7; 95% CI 1.4 to 16.0), and incomplete aneurysm obliteration (OR 2.6; 95% CI 1.0 to 6.6). Higher impact journals were more likely to publish papers on endovascular techniques, particularly flow diverter stents.

None of the methods is unequivocally superior. Considering its inefficiency, stent-assisted coiling should be undertaken with caution. A time-delimited systematic review is needed to establish the most accurate treatment for ruptured BBAs 2).

Case series

A retrospective review of 10 patients allowed a division into 4 distinct subtypes: Type I (classic), Type II (berry-like), Type III (longitudinal), and Type IV (circumferential). These subtypes may at times be progressive stages in the arterial anomaly, and could represent a continuum. Each subtype described in this paper presented its own pitfalls and required specific surgical adaptations. Upon reviewing the literature the authors retained 35 studies involving a total of 61 cases of blister aneurysms, and all cases were able to be classified into 1 of these 4 distinct subtypes.

Although they share some common characteristics, blister aneurysms may be divided into distinct subtypes, suggestive of a continuum. Such a classification with a detailed description of each type of blister aneurysm would allow for better recognition to anticipate complications during intervention and better assess the different treatment strategies according to the subtypes 3).

Case reports

2016

A 29-year-old man presented with subarachnoid hemorrhage and a ruptured dorsal variant internal carotid artery aneurysm. Despite a technically successful treatment with a single FDS, a second catastrophic hemorrhage occurred during the course of his hospitalization.

This case highlights the risk of hemorrhage during the period after deployment of a single FDS. Ruptured aneurysms, especially of the blister type, are at risk for rehemorrhage while the occlusion remains incomplete after flow diversion 4).

Videos

Intracranial blister aneurysms: clip reconstruction techniques

1)
Cıkla U, Baggott C, Başkaya MK. How I do it: treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery by extracranial-to-intracranial bypass and trapping. Acta Neurochir (Wien). 2014 Nov;156(11):2071-7. doi: 10.1007/s00701-014-2212-8. Epub 2014 Sep 9. PubMed PMID: 25196640.
2)
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 May;8(5):488-94. doi: 10.1136/neurintsurg-2015-011665. Epub 2015 Mar 19. PubMed PMID: 25792038.
3)
Bojanowski MW, Weil AG, McLaughlin N, Chaalala C, Magro E, Fournier JY. Morphological aspects of blister aneurysms and nuances for surgical treatment. J Neurosurg. 2015 Nov;123(5):1156-65. doi: 10.3171/2014.11.JNS141004. Epub 2015 May 22. PubMed PMID: 26053352.
4)
Mazur MD, Taussky P, MacDonald JD, Park MS. Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent. Neurosurgery. 2016 Nov;79(5):E634-E638. PubMed PMID: 27759680.
blister_aneurysm.txt · Last modified: 2016/11/01 17:15 (external edit)