what i learned from a complex ruptured aneurysm€¦ · blister-type aneurysms the outer wall of...
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What I Learned from a
Complex Ruptured
Aneurysm
Italo Linfante MD, FAHA Director Endovascular Neurosurgery
Interventional Neuroradiology
Miami Cardiac and Vascular Institute
Clinical Professor
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Disclosures
Medtronic/Covidien: Consultant, Speaker, Proctor
for Pipeline
Stryker: Consultant, Speaker
Codman Neurovascular: Consultant, Speaker
Surpass, InNeuroCo: Stock holder
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Baptist Hospital of Miami
Dr Guilherme Dabus, Dr Michael Maych
700 INR cases/year
120-150 Aneurysms
20 Vascular Malformations
>100 Acute Stroke Interventions
20-30 CAS
20-30 tumor embolization
> 300 diagnostic angiograms
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2007
35 yo woman from Guatemala visiting
family in Miami has sudden onset of
severe headache, N&V followed by
unresponsiveness
CT: Fisher Grade III SAH
Neuro Exam improves a after
ventriculostomy
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Blister-Type Aneurysms
Blister-type aneurysms were initially
described in 1986 as arising from the dorsal
aspect of ICA
0.9-6.5% of ICA aneurysms and < 1% of all
intracranial aneurysms
After the initial description as ICA
aneurysms, they have now also been reported
in MCA, ACA/Acomm, Basilar artery and
PICA
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Blister-Type Aneurysms
The outer wall of the artery is comprised only by
adventitia and/or thrombus often adherent to overlying
pia
As a result, a blister-type lesion is a fragile structure
without a discernable neck
If this thin wall is disrupted by surgical manipulation or
by minimal changes in arterial blood pressure, it may
result in catastrophic intracranial hemorrhage
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Patient
What to do?
1. Nothing?
2. Clipping?
3. Stent-coil?
4. Coil?
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Patient Vasospasm, treated with angioplasty and
IA nicardipine
Regrowth, on angio. Re-coiled
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Patient Vasospasm, treated with angioplasty and
IA nicardipine again
Doing very well neurologically until day
14 post SAH,
Off-dilantin on ASA plus plavix, she
developed a GTC followed by
unresponsiveness.
Intubated
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Patient Regrowth, on angio
Re-coiled
Second stent placed (Enterprise)
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Patient D/C to rehab at day 24 post SAH
Dysarthria
Right arm and leg weakness 4/5, gait ataxia
Dismetria on finger to nose R >L
Back to Guatemala by commercial plane day 35
post SAH able to walk with mild assistance
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One Year Later…
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Ruptured Blister Aneurysms Presentation is typically SAH related to lesion rupture
Re-bleed is very common in the first week and is
associated with high mortality
Conventional microsurgical approaches including
clipping and parent artery trapping are associated with
high morbidity and mortality
Stent, multiple stent and coil is described with
acceptable rates of procedural complications, however
it has high recurrence rate Meling TR et al , Blood blister-like aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: treatment and
outcome. J Neurosurg. 2008 Apr;108(4):662-71.
Ogawa A et al Aneurysms at nonbranching sites in the surpaclinoid portion of the internal carotid artery: internal carotid artery trunk aneurysms.
Neurosurgery. 2000 Sep;47(3):578-83.
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2 Years Later…
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Patient 56 year old man sudden onset of “worst
headache of his life”
CT: SAH
Angio: left MCA blister aneurysm
OR for clipping/wrapping
Rupture of the MCA during clipping
Patient expired 5 days later
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3 Years Later…
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Phone Call Called by the Chief of Oncologic Surgery at BH
“My beautiful 27 year old sister (MD, resident in Pediatrics at UM) has a SAH and is in the ER”
She had sudden onset of “worst headache of her life” at the gym
Loss of consciousness with mild right face arm
and leg weakness
On admission H&H 3
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confidential: for internal use
only
29
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Patient
What to do?
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Flow Diversion
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FD in Blisters
April 6, 2011 FDA approved Pipeline
Embolic Device (PED)
Because of the purely endoluminal nature of
aneurysmal occlusion, PED may represent
an ideal option to repair ruptured BA
There is a problem…. Completely OFF-LABEL
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Blister: Treatment with
Flow Diverter
EVD was placed
Loaded with 600 mg of plavix, 325 mf ASA
after EVD placement
The day after, Plavix 75 mg and ASA 325
Taken to angio for treatment
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Set-up
Neuron Max
Navien 0.58
Marksman
Synchro 0.014
Pipeline Flex 2.5 x 14 mm
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Pipeline FLEX
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Patient
Patient did very well post PED placement
Not significant vaspasm
EVD was D/C
Patient went back to work full time 3
months after the SAH
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8 months follow-up
angio
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Patient
45 year old man with sudden onset headache
On admission H&H 1
CT SAH
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5 months follow-
up angio
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Patient
53 year old man with sudden onset headache
On admission H&H 3
CT SAH FG3
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6 months follow-
up angio
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FD in Blister Aneurysms
10 cases ICA or MCA blisters at BH and
BU
Excellent technical result with obliteration
with the blister
1 patient required multiple PED
1 patient expired (H&H 4, severe
vasospasm)
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So What Did I Learn?
Ruptured BA are very malignant
High recurrence/re-bleed
Clipping/wrapping high mortality
Coil or Multiple Stent-coil has high
recurrence/re-bleed
FD promising tool for ruptured, blister-type
aneurysm
More data needed
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