Blister aneurysms- Evolution of Endovascular management

Vipul GuptaNeurointerventional SurgeryArtemis Agrim Institute of Neurosciences

Blister aneurysms …

Classical ICA blister aneurysms Dissecting aneurysm with a bleb Very small berry aneurysms

Small Blister/dissecting…

“Very small, friable, symptomatic” Blister aneurysms (BA) are rare lesions characterized by a

hemispherical shape and fragile walls Non-branching sites from the dorsomedial wall of the

internal carotid artery (ICA), anterior communicating (AComA) and basilar artery …

Small size & atypical location- RA & 3D needed Blister/disecting- rapid change in size and morphology in

follow-up angiograms

Owaga A et al , Neurosurgery 2000;47:578

Meling TR et al J Neurosurg 2008;108:662

Sim SY et al J Neurosurg 2006;105:400

Management…

Pathology - focal wall defects covered by a thin layer of fibrous tissue and adventitia and lack of usual collagenous layerSurgical Options - Direct clipping, clipping plus wrapping, wrapping alone, clipping with Sundt encircling graft clips, encircling silicone clip application, primary suturing of ICA, vascular staple clip closure of ICA and trapping with or without extracranial-intracranial bypass

High risk of premature rupture during surgery, large lacerationsEndovascular- difficult to coil, friable, continued growth, stent needed (issues in SAH)Shikawa T, Neurosurgery 1997;40:403Lee BH et al J Neurosurg 2008

Issue- blister; control- protamine, coils

Stents

Flow modification Intimal growth and healing Change of angles

Issues Persistent fillingAnti-platelet therapy in SAHSingle/double/flow divertor

Classical blister aneurysm

34-year M, SAH

Stent …

Further evolution – flow diverters (stents)

D E F

B CA B

B

C D

A

21/12/15

24/12/15

17 patients: SS, ODS, SS+Coil 1 rebleed (died)Good outcome on f/u – 82%Mortality – 18%

Blister Aneurysm

Our experience with FD vs non FD

Complete occlusion – 89% vs 71% i.f.o FD

Repeat treatment – none vs 11.7% i.f.o FD

Rebleed resulting in death – none vs 5.8% i.f.o FD

Submitted for publication

Learning points

• FD was safe and effective in these aneurysms and compared favorably with our previously reported results with stent(single/overlapping) and coiling

• In our series loading with Pasugrel and ecospirin was safe and effective for flow diverter placement in acutely ruptured blister aneurysms

Antiplatelet protocol: 2 hrs prior to stent deploymentEcosprin 150 mg & Prasugrel 50 mg

Heparin 3000 IU at start of procedure1000 IU to 2000 IU prior to stent deploymentACT 300 (x 2 upper limit of normal)

Dissections with blister EVD

2-overlapping Enterprise stents

A B C

D E F

Very small aneurysms …

Dissecting blister aneurysm – poor gradeEVD

2-overlapping Enterprise stents

Blister/dissecting aneurysms

Small blister/dissecting

Small blister/dissecting- important to detect and recognize

Difficult cases for surgery or endovascular Previous Options- single stent, overlapping

stents, stent and coil Current TOC in ICA – FD Careful anti-platelet protocol Distinguish between blister vs dissecting vs

very small berry

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Dr Vipul Gupta

Thank you ….