INR scope

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.

Monday 14 March 2022
  • 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.
    Blister aneurysm

     

     

     

    • 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.

     

    Blister aneurysm

     

    BRAIN CT ANGIOGRAPHY

    • Blister aneurysm.

     

    Blister aneurysm

     

    Blister aneurysm

     

    DSA

    • Blister aneurysm in right ICA.

     

    Blister aneurysm

     

    • Movie 1:
      Angiography
    blood-blister-aneurysm-movie-1-angiography - You do not have permission to view this object.
    • Movie 2:
      Microcatheter in MCA
    blood-blister-aneurysm-movie-2-micro-catheter-in-mca - You do not have permission to view this object.
    • Movie 3:
      Deployment of FDS in right carotid, proximal to ICA bifurcation to cavernous segment.
    blood-blister-aneurysm-movie-3-deployment-of-fds-in-right-carotid - You do not have permission to view this object.
    • Movie 4:
      Immediate angiography after stenting: No evidence of aneurysm
    blood-blister-aneurysm-movie-4-immediate-angiography-after-stenting - You do not have permission to view this object.
    • Movie 5:
      Immediate angiography after stenting: No evidence of aneurysm
    blood-blister-aneurysm-movie-5-immediate-angiography-after-stenting-no-evidence-of-aneurysm - You do not have permission to view this object.

     

    • Immediate angiography after stenting

     

    Blister aneurysm

     

    • Stent in carotid.

     

    Blister aneurysm

     

    POST-OPERATION

    • GCS 15.
    • Normal neurologic exam.

     

    Blister aneurysm

     

    • CT angiograph 6 months later.

     

    Blister aneurysm

     

    CONCLUSION

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

READ & SHARE TOPIC

Endovascular Treatment of Isolated Transverse Sinus Dural-AV Fistula

READ & SHARE TOPIC

Natural course of extensive intimal hyperplasia after aneurysm-treatment with a flowdiverter

LECTURE

conference room and Live streaming 3:50:01 pm Flow Diversion Treatment of Ruptured Basilar Apex Blister Aneurysm

LECTURE

conference room and Live streaming 8:10:01 am M1 dissecting aneurysm treated with telescoping stent technique

LECTURE

conference room and Live streaming 2:40:01 pm Urgent treatment of right PCA dissecting aneurysm