Treatment of ruptured blood blister-like aneurysms of the internal carotid artery with flow-diverting stents: Case report and review of pharmacological management

Abstract

Background: Rupture of a blood-blister like aneurysm (BBLA) of the internal carotid artery (ICA) is a rare etiology of subarachnoid hemorrhage (SAH). Historically, BBLAs have been difficult to treat. Open surgical clipping and endovascular coiling techniques have both had high rates of failure. Recently, flow-diverting stents (FDS) have been used to treat BBLAs with success, but concerns exist regarding the need for dual anti-platelet therapy, the delayed occlusion of the aneurysm that occurs with flow-diversion, and the potential difficulty of treating cerebral vasospasm and hydrocephalus. Methods: Clinical data and imaging from the index case were reviewed, and a systematic review of the medical literature was performed. Medical databases including PubMed and Medline were searched using multiple combinations of keywords. The bibliographies of each result were then used to identify additional publications. Only English language case reports of ruptured, intracranial ICA blood blister-like aneurysms treated exclusively with flow-diverting stents were included. Results: Given the results from our literature search and this patient's characteristics, we chose to treat her ruptured BBLA with a FDS. Although the FDS was deployed successfully, her clinical course was complicated by cerebral vasospasm, which was managed with induced hypertension. Subsequently, she developed hydrocephalus and underwent successful placement of a ventriculoperitoneal shunt while on dual antiplatelet therapy, which was briefly held. She had no operative complications and made an excellent recovery. Follow-up angiography performed at 3 and 6 months confirmed total occlusion of the aneurysm. Conclusions: A literature review revealed numerous successful treatments of ruptured BBLA with FDS monotherapy. A variety of different pharmacological treatment adjuncts were used; oral aspirin and clopidogrel being the most common. Overall, patients with ruptured BBLAs of the ICA treated only with FDS monotherapy had superior outcomes when compared to patients with ruptured BBLAs treated with open microsurgical clipping or endovascular coiling alone. Keywords: Blister aneurysm, Endovascular, Flow-diverting stent, Internal carotid artery, Pipeline, Subarachnoid hemorrhage