Neurointervention.  2017 Mar;12(1):40-44. 10.5469/neuroint.2017.12.1.40.

A Case of Ruptured Blood Blister-like Aneurysm Treated with Pipeline Embolization Device: Clinical Significance of Fetal-type Posterior Communicating Artery

• Park KS
• Kang DH
• Son WS
• Park J
• Kim YS
• Kim BM

• KMID: 2371757
• DOI: http://doi.org/10.5469/neuroint.2017.12.1.40

Abstract

Blood-blister like aneurysms (BBAs) are challenging lesions because of their wide fragile neck. Flow-diverting stents (FDSs), such as the Pipeline Embolization Device (PED), have been applied to treat BBAs less amenable to more established techniques of treatment. However, the use of FDSs, including the PED, in acute subarachnoid hemorrhage (SAH) still remains controversial. We report a case of aneurysm regrowth following PED application for a ruptured BBA that overlapped the origin of the dominant posterior communicating artery (PCoA), which was successfully treated after coil trapping of the origin of the fetal-type PCoA. And, we discuss the clinical significance of the fetal-type PCoA communicating with a BBA in terms of PED failure.

Keyword

Blood blister-like aneurysm; Flow diversion; Pipeline Embolization Device; Fetal circulation; Coil embolization

MeSH Terms

Aneurysm*
Arteries*
Embolization, Therapeutic
Neck
Stents
Subarachnoid Hemorrhage

Figure

• 

  Fig. 1 Studies and an endovascular treatment at other local hospital (A) An immediate CT scan showed a diffuse, thick subarachnoid hemorrhage in the basal cisterns and bilateral sylvian fissures. (B) DSA revealed a small hemispheric bulge at the dorsomedial wall of the communicating segment ICA (arrow). (C and D) Three self-expandable stents (LVIS) were deployed into communicating segment of the ICA. (E) Follow-up DSA at 5 days demonstrated regrowth of the BBA (arrow).

• 

  Fig. 2 The first PED implantation procedure for the BBA (A) Baseline angiography in our institute showed more prominent growth of the BBA and some amount of in-stent thrombosis. (B and C) Subtracted and non-subtracted angiographies after the first PED implantation, which demonstrated complete flow diversion of the BBA but also showed occlusions of ipsilateral proximal ACA and PCoA. The following left ICA and VA angiographies showed sufficient collateral flow through anterior and posterior communicating arteries.

• 

  Fig. 3 Follow-up DSA and additional treatment in our institute (A) Follow-up DSA 10 days after the first PED deployment revealed intraaneurysmal contrast filling (arrow) and the reopening of the flow of ACA and PCoA. (B) Firstly, balloon angioplasty within the first PED was performed to achieve complete apposition to the ICA wall. (C) Then, one more PED was implanted within the previous PED for stronger flow diversion (D) However, immediate DSA still showed contrast filling into the BBA (arrow). This could be possibly explained by the inflow from the ICA to the fetal-type PCoA, which was connected to the neck of the BBA (curved arrow). (E) Especially, Allcock test showed the connection between BBA and PCoA well (arrow: BBA, curved arrow: the connection between BBA and PCoA). (F, G, and H) Eventually, coil trapping at the origin of the fetal-type PCoA was attempted through the PCoA. (I, J, K, and L) Final DSA demonstrated complete occlusion of the origin of the PCoA and no contrast filling into the BBA.

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