Blood blister aneurysm

Author: HOSSEINI Ehsan Mohammad

Find out how Dr. Ehsan Mohammad Hosseini (Assistant Professor of Neurosurgery, Namazi Hospital, Shiraz University of Medical Sciences, Iran) treated a 55-year-old female patient suffering from a blister-like aneurysm in dorsal surface of right supra clinoid carotid.

• Case

  CASE PRESENTATION

  • Blood blister-like aneurysms (BBAs) include arterial vascular lesions from non-branching sites (dorsal or anterior wall). 
  • Most classic location in the ICA.

   

   

   

  • Typical presentation: acute subarachnoid hemorrhage (SAH), mostly in younger female.
  • The classical morphology is small, hemispherical-shaped and bulging from non-branching sites on the ICA.

   

  THE PHYSIOPATHOLOGY

  • Main hypothesis: Dissection, fragile fibrin layer in a focal arterial segment, and calcification changes.
  • The extremely fragile wall of BBAs makes the management complicated and risky.
  • More recently, the multilayer in-stent technique has been described for false aneurysms and for blister-like aneurysms.
  • Coiling of BBAs has been associated with a high intraprocedural rupture rate. The possibility of performing a parent vessel reconstruction appears to be a more physiological method to avoid intra-saccular treatments.

   

  TREATMENT

  • Direct clipping, clipping after wrapping, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass.

   

  CASE PRESENTATION

  • 55 y/o lady with sudden onset severe headache.
  • GCS: 15.
  • FND: negative.
  • Past medical Hx: HTN.
  • Drug Hx: captopril.
  • Brain CT: diffuse SAH in basal cistern and Sylvian fissure with mild hydrocephalus.
  • Brain CTA: Blister Like Aneurysm in dorsal surface of right supra clinoid carotid.
  • DSA: confirm the diagnosis.

   

  PLAN

  • FDS in right carotid.
  • Before stenting: loading dose of antiplatelet with ASA 650 mg and Clopidogrel 600 mg.
  • During stenting: 5000 unit heparin.
  • After stenting: for 3 month ASA 80 mg and Clopidogrel 75 mg daily and long life ASA 80 mg.

   

  INITIAL BRAIN CT

  • Subarachnoid hemorrhage in the basal cistern and Sylvian fissure, more prominent on right side.

   

   

  BRAIN CT ANGIOGRAPHY

  • Blister aneurysm.

   

   

   

  DSA

  • Blister aneurysm in right ICA.

   

   

  • Movie 1:
    Angiography

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  • Movie 2:
    Microcatheter in MCA

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  • Movie 3:
    Deployment of FDS in right carotid, proximal to ICA bifurcation to cavernous segment.

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  • Movie 4:
    Immediate angiography after stenting: No evidence of aneurysm

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  • Movie 5:
    Immediate angiography after stenting: No evidence of aneurysm

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  • Immediate angiography after stenting

   

   

  • Stent in carotid.

   

   

  POST-OPERATION

  • GCS 15.
  • Normal neurologic exam.

   

   

  • CT angiograph 6 months later.

   

   

  CONCLUSION

  • FDS in single or multilayer may be an effective and safe treatment option in blister-like aneurysms.