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Intra-aneurysmal air after flow diversion treatment in intracranial aneurysms: incidence, characteristics and clinical significance

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Abstract

Objective

To describe the rate and characteristics of air bubble retention (ABR) within cerebral aneurysms treated by flow diversion.

Methods

Procedural flat detector CT (FDCT) studies were scrutinized for the presence of air bubbles (density < − 200 HU) in patients treated by flow diversion. Patients with intrasaccular treatment or previous clipping were excluded. Clinical outcomes, procedural angiograms, aneurysm characteristics and imaging features of air within the aneurysm were evaluated.

Results

Bubbles were noted in 17.1% of 105 aneurysms in 85 FDCTs. Aneurysms with ABR were significantly larger (mean diameter: 18.9 versus 7.5 mm, P < 0.0001). There was a trend for the use of multiple devices during the treatment of these aneurysms (72.2% vs 49.4%, P = 0.071). All of the bubbles were located rostrally in the aneurysm sac and were smaller than 6 mm (mean diameter: 2.1 ± 1.3 mm). None of the patients had post-procedural neurological deterioration. The air had spontaneously disappeared on follow-up CT images (available in 12 patients) obtained at a mean follow-up duration of 48 h.

Conclusions

ABR is not infrequent in cerebral flow diversion procedures. It is a clinically silent and self-limited technical complication. We propose air entrapment or filtration through the flow diverter as causative factors.

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Authors and Affiliations

  1. Department of Radiology, Faculty of Medicine, School of Medicine, Hacettepe University, Ankara, Turkey

    Osman Ocal & Anıl Arat

Authors
  1. Osman Ocal
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  2. Anıl Arat
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Corresponding author

Correspondence to Anıl Arat.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This retrospective study was approved by the ethics committee of our university hospital.

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Figure 1

(a-p) FDCT images of all of the cases with intraaneurysmal air in this series in a variety of oblique planes showing both the air and the adjacent flow diverter. (PDF 624 kb)

Figure 2

Basic flow model constructed to simulate air displacement during flow diverter deployment. Arrows indicate the straight arm of the Y-connector which serves as the parent artery, the side arm simulates a small aneurysm (arrow head). Pulsatility of the flow was maintained by turning the roller clamp of the fluid line “on and off” in constant cycles. The fluid line was connected with a drip chamber to a saline bag pressurized at 300 mmHg and air was introduced during cycles by puncturing the yellow rubber connectors with a 26 G hypodermic needle. The fluid in the efferent limb of the line was let to flow freely in an empty fluid bag (PDF 281 kb)

Video 1

Left ICA arteriogram in working projection just before flow diverter deployment shows the air bubble generated during catheterization (the same patient as in Fig. 2) (MOV 512 kb)

Video 2

a Biplane left ICA arteriogram in working projection obtained during the deployment of the flow diverter is suggestive of filtration of air and its coalescence to form a bubble that migrates to rostral portion of the aneurysm (the same patient as in Fig. 1) (MOV 640 kb)

b

Biplane left ICA arteriogram in working projection obtained during the deployment of the flow diverter is suggestive of filtration of air and its coalescence to form a bubble that migrates to rostral portion of the aneurysm (the same patient as in Fig. 1) (MOV 624 kb)

Video 3

Despite rigorous flushing of the flow diverter before insertion into guiding catheter, air bubbles are entrapped between struts of the device (MP4 10234 kb)

Video 4

During the on/off cycles, air was introduced within the 3 mm Surpass flow diverter with a long needle from the efferent limb to observe how it behaved, then 0.01 mL of air was injected from the afferent limb. Please note that the air within the lumen of the device tends to stay inside the flow diverter throughout the cycles whereas the air bubble at the edge of the “funnel” of flow diverter formed as the device exits the delivery catheter, remains entrapped at the interstices of the diverter without entering the lumen of the flow diverter. With the injection of 0.1 mL of air via the afferent limb, this air bubble and the incoming air bubble both fragment and filter into the side-arm of the connector where some of the smaller bubbles are seen to coalesce (MP4 12169 kb)

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Ocal, O., Arat, A. Intra-aneurysmal air after flow diversion treatment in intracranial aneurysms: incidence, characteristics and clinical significance. Jpn J Radiol 37, 549–554 (2019). https://doi.org/10.1007/s11604-019-00842-2

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  • DOI: https://doi.org/10.1007/s11604-019-00842-2

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