Introduction: Ruptured blister aneurysms (RBA) present many challenges to neurosurgeons due to a high propensity for re-bleeding during intervention. The pipeline embolization device (PED) is a low porosity mesh approved for treatment of unruptured aneurysms larger than 10mm on the internal carpotid artery from the petrous to ophthalmic segment. The authors present 11 patients treated with PED and discuss the process and results of this novel application of flow diverters.
Methods: Medical records of patients who presented with RBA from May 2011 to March 2013 were retrospectively reviewed at six institutions in the US. All relevant data points including patient demographic information, medical and medication history, initial clinical assessment, aneurysm characteristics, antiplatelet regimen, procedural characteristics, perioperative complication rates, aneurysm obliteration rates, and postoperative outcomes were independently compiled.
Results: A total of 12 RBA in 11 patients were treated during the study period. Nine (75%) were treated with a single PED, one was treated with two PEDs, one was treated with coils and one PED, and one was treated with coils and two PEDs. Five of 11 patients (45%) suffered perioperative complications. Three (27%) were considered major perioperative complications: middle cerebral artery territory infarct, vision loss, and death. Seven of eight patients demonstrated a complete obliteration of the aneurysm in postoperative imaging. One patient had persistent small neck remnant on angiography at six months postoperatively. Early clinical outcomes were favorable (mRS 0-2) in all 10 survivors.
Conclusions: This study demonstrates feasibility and safety of PED to treat RBA, with good initial results. A decision making process with proper antiplatelet regimen introduction and management is key. Dual antiplatelet-related bleeding complications seem similar to previously reported stent assisted coiling therapy studies for the same population. More cases are needed to define the precise role of flow diverters in this complex rupture aneurysm subtype.
Patient Care: The goal of this retrospective cohort study is to determine the peri-operative complications, aneurysm obliteration rates and early clinical results of using pipeline embolization device (PED) in the treatment of ruptured blister aneurysm (RBA). To our knowledge, this multi-center series is the largest cohort of patients with RBA that were treated with PED. Widespread use of PED is relatively recent and there are currently limited data in literature investigating their clinical implications. In addition, data regarding the treatment of ruptured blister aneurysms is scarce and the clinical outcomes of using conventional endovascular treatment such as coiling, stenting or stent assisted coiling or open surgery have been subpar. PED may be better suited to treat blister aneurysms due to its flow diverting property. Based on our early results, PEDs may be considered the first line therapy when treating these extremely challenging RBAs. Our study validates the safety and feasibility of using PED in patients with RBA. It also calls for future investigations into its precise role in the treatment of complex aneurysms.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Appreciate the complexity and challenges of treating ruptured blister aneurysms and be aware of peri-operative complications of treating RBA with PED 2) Discuss, in small groups pros and cons of different treatment options for ruptured RBA 3) Identify a feasible and safe treatment plan for the ruptured blister aneurysms