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Treatment with a flow diverter-assisted coil embolization for ruptured blood blister-like aneurysms of the internal carotid artery: a technical note and analysis of single-center experience with pooled data

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A Correction to this article was published on 22 December 2023

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Abstract

Treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) with flow diverters (FDs) has become widespread in recent years. However, ruptured blood blister-like aneurysm (BBA) of ICA treatment with flow diverter-assisted coil embolization (FDAC) remains controversial. Moreover, limited direct comparative studies have been conducted between the two treatment modalities, FDs and FDAC, for BBAs. The purpose of this study was to document our experience and evaluate the effectiveness and safety of FDAC. We conducted a retrospective analysis of clinical and radiological information from ten patients who experienced ruptured BBAs of the supraclinoid ICA at our center from January 2021 to February 2023. The technical details of FDAC for ruptured BBAs were described, and the technical steps were named “pipeline embolization device (PED)-Individualized shaping(microcatheter)-Semi deploying-Rivet(coils)-Massage(microwire)” as the PEISSERM technique. Clinical outcomes were assessed using the modified Rankin Scale (mRS), whereas radiological results were determined through angiography. A pooled analysis was implemented, incorporating data from literature sources that reported perioperative and long-term clinical and angiographic outcomes of ruptured BBAs treated with FD and FDAC strategies, along with our data. Data in our analysis pool were categorized into FD and FDAC strategy groups to explore the preferred treatment modalities for BBAs. The PEISSERM technique was utilized to treat ten patients, seven males, and three females, with an average age of 41.7 years. A single PED was deployed in conjunction with coils in all ten patients. All PEDs were documented to have good wall apposition. The immediate postoperative angiograms demonstrated Raymond grade I in ten aneurysms. Angiographic follow-up of nine patients at 4–25 months showed total occlusion of the aneurysms. At the most recent follow-up, the mRS scores of nine patients hinted at a good prognosis. Pooled analysis of 233 ICA-BBA cases of FD revealed a technical success rate of 91% [95% confidence interval (CI), 0.88 to 0.95], a rate of complete occlusion of 79% (95% CI, 0.73 to 0.84), a recurrence rate of 2% (95% CI, 0.00 to 0.04), a rebleed rate of 2% (95% CI, 0.00 to 0.04), and the perioperative stroke rate was 8% (95% CI, 0.04 to 0.11). The perioperative mortality was 4% (95% CI, 0.01 to 0.07). The long-term good clinical outcome rate was 85% (95% CI, 0.80 to 0.90). The mortality rate was 6% (95% CI, 0.03 to 0.09). Results from the subgroup analysis illustrated that the FDAC strategy for BBAs had a significantly higher immediate postoperative complete occlusion rate (P < 0.001), total occlusion rate (P = 0.016), and a good outcome rate (P = 0.041) compared with the FD strategy. The FDAC strategy can yield a higher rate of good outcomes than the FD strategy. The PEISSERM technique employed by the FDAC is a reliable and effective treatment approach as it can minimize the hemodynamic burden of BBA’s fragile dome, thereby achieving an excellent occlusion rate. The PEISSERM technique in the FDAC strategy contributes to understanding the BBA’s treatment and offers a potentially optimal treatment for BBA.

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Funding

The study was supported by the National Natural Science Foundation of China (Nos. 82171327 and 82302372).

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Author notes

  1. Yi-Bin Zhang, Pei-Sen Yao, Hao-Jie Wang, and Bing-Sen Xie have contributed equally to this work.

Authors and Affiliations

  1. Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China

    Yi-Bin Zhang, Pei-Sen Yao, Hao-Jie Wang, Bing-Sen Xie, Deng-Liang Wang, Liang-Hong Yu, Yuan-Xiang Lin, Shu-Fa Zheng & De-Zhi Kang

  2. Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China

    Yi-Bin Zhang, Pei-Sen Yao, Hao-Jie Wang, Bing-Sen Xie, Deng-Liang Wang, Liang-Hong Yu, Yuan-Xiang Lin, Shu-Fa Zheng & De-Zhi Kang

  3. Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, China

    Jia-Yin Wang

  4. Department of Neurosurgery, The Affiliated People’s Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, 350005, China

    Mei Zhu

  5. Fujian Provincial Clinical Research Center for Neurological Diseases, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China

    Yuan-Xiang Lin & De-Zhi Kang

  6. Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China

    Yuan-Xiang Lin, Bin Gao, Shu-Fa Zheng & De-Zhi Kang

  7. Clinical Research and Translation Center, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China

    De-Zhi Kang

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Contributions

Y-BZ, D-ZK, and S-FZ designed the study; H-JW, B-SX, MZ, and D-LW collected and analyzed data; Y-BZ, H-JW, J-YW, MZ, BG, and S-FZ helped with the figures and result in interpretation; J-YW and BG conducted the literature search and reviewed; Y-BZ, P-SY, H-JW, B-SX, and S-FZ drafted the manuscript; P-SY, Y-XL, D-ZK, and S-FZ reviewed and revised the manuscript; D-ZK and S-FZ were identified as the guarantor of the paper, taking responsibility for the integrity of the work as a whole. All authors read and approved the final manuscript.

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Correspondence to Shu-Fa Zheng or De-Zhi Kang.

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The studies involving human participants were reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Fujian Medical University. Written informed consent from the participant’s legal guardian/next of kin was not required to participate in this study under the national legislation and institutional requirements.

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Zhang, YB., Yao, PS., Wang, HJ. et al. Treatment with a flow diverter-assisted coil embolization for ruptured blood blister-like aneurysms of the internal carotid artery: a technical note and analysis of single-center experience with pooled data. Neurosurg Rev 46, 305 (2023). https://doi.org/10.1007/s10143-023-02216-9

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