Blister aneurysms- Evolution of Endovascular management

1. Vipul Gupta
Neurointerventional Surgery
Artemis Agrim Institute of
Neurosciences

2. Blister aneurysms …
 Classical ICA blister aneurysms
 Dissecting aneurysm with a bleb
 Very small berry aneurysms

3. 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

4. Management…
 Pathology - focal wall defects covered by a thin layer of fibrous
tissue and adventitia and lack of usual collagenous layer
Surgical 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 lacerations
Endovascular- difficult to coil, friable, continued growth, stent
needed (issues in SAH)
Shikawa T, Neurosurgery 1997;40:403
Lee BH et al J Neurosurg 2008

5. Issue- blister;
control- protamine,
coils

6. Stents
 Flow modification
 Intimal growth and healing
 Change of angles
Issues
Persistent filling
Anti-platelet therapy in SAH
Single/double/flow divertor

7. Classical blister aneurysm
34-year M, SAH

9. Stent …

10. Further evolution –
flow diverters (stents)

11. D E F
B CA B

12. B
C D
A

14. 21/12/15
24/12/15

15. 17 patients: SS, ODS, SS+Coil
1 rebleed (died)
Good outcome on f/u – 82%
Mortality – 18%
Blister Aneurysm

16. 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

17. 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
deployment
Ecosprin 150 mg & Prasugrel 50 mg
Heparin 3000 IU at start of procedure
1000 IU to 2000 IU prior to stent deployment
ACT 300 (x 2 upper limit of normal)

19. Dissections with blister
EVD
2-overlapping Enterprise stents

20. A B C
D E F

23. Very small aneurysms …

24. Dissecting
blister
aneurysm –
poor grade
EVD
2-overlapping Enterprise stents
Blister/
dissecting
aneurysms

26. 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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28. Thank you ….