Ryan Robert W, Khan Amir S, Barco Rebecca, Choulakian Armen
Department of Neurosurgery, UCSF Fresno, California.
Neurosurg Focus. 2017 Jun;42(6):E11. doi: 10.3171/2017.3.FOCUS1757.
OBJECTIVE Ruptured blister aneurysms remain challenging lesions for treatment due to their broad, shallow anatomy and thin, fragile wall. Historical challenges with both open microsurgical approaches and intrasaccular endovascular approaches have led to increased use of flow diversion for management of these aneurysms. However, the optimum paradigm, including timing of treatment, use of dual antiplatelet therapy, and number of flow-diverter devices to use remains unknown. The authors describe their experience with ruptured blister aneurysms treated with flow diversion at their institution, and discuss rates of rebleeding and number of devices used. METHODS All patients presenting with subarachnoid hemorrhage from a ruptured blister aneurysm and treated with Pipeline flow diversion were identified. Patient demographic data, clinical status and course, need for external ventricular drain (EVD), timing of treatment, and angiographic details and follow-up were recorded. RESULTS There were 13 patients identified (11 women and 2 men), and 4 had multiple aneurysms. Two aneurysms were treated on initial angiography, with average time to treatment of 3.1 days for the remainder, after discussion with the family and institution of dual antiplatelet therapy. Device placement was technically successful in all patients, with 2 patients receiving 2 devices and the remainder receiving 1 device. There was 1 intraoperative complication, of a wire perforation causing intracerebral hemorrhage requiring decompressive craniectomy. Three patients had required EVD placement for management of hydrocephalus. There was no rebleeding from the target lesion; however, one patient had worsening intraventricular hemorrhage and another had rupture of an unrecognized additional aneurysm, and both died. Of the other 11 patients, 10 made a good recovery, with 1 remaining in a vegetative state. Nine underwent follow-up angiography, with 5 achieving complete occlusion, 2 with reduced aneurysm size, and 2 requiring retreatment for aneurysm persistence or enlargement. There were no episodes of delayed rupture. CONCLUSIONS Pipeline flow diversion is a technically feasible and effective treatment for ruptured blister aneurysms, particularly in good-grade patients without hydrocephalus. Patients with a worse grade on presentation and requiring EVDs may have higher risk for bleeding complications and poor outcome. There was no rebleeding from the target lesion with use of a single device in this series.
破裂的水泡状动脉瘤因其广泛、表浅的解剖结构以及薄而脆弱的壁，在治疗上仍然是具有挑战性的病变。开放显微手术方法和囊内血管内治疗方法在历史上所面临的挑战，导致越来越多地使用血流导向装置来治疗这些动脉瘤。然而，最佳的治疗模式，包括治疗时机、双重抗血小板治疗的使用以及血流导向装置的使用数量，仍然未知。作者描述了他们所在机构使用血流导向装置治疗破裂水泡状动脉瘤的经验，并讨论了再出血率和装置使用数量。方法：确定所有因破裂水泡状动脉瘤导致蛛网膜下腔出血并接受Pipeline血流导向治疗的患者。记录患者的人口统计学数据、临床状况和病程、是否需要外置脑室引流（EVD）、治疗时机、血管造影细节及随访情况。结果：共确定13例患者（11例女性和2例男性），4例有多个动脉瘤。2例动脉瘤在初次血管造影时接受治疗，其余患者在与家属讨论并开始双重抗血小板治疗后，平均治疗时间为3.1天。所有患者的装置置入在技术上均获成功，2例患者使用了2个装置，其余患者使用1个装置。术中出现1例并发症，即导丝穿孔导致脑出血，需行去骨瓣减压术。3例患者因脑积水需要放置EVD。目标病变未发生再出血；然而，1例患者脑室内出血加重，另1例患者未被识别的额外动脉瘤破裂，两人均死亡。其余11例患者中，10例恢复良好，1例仍处于植物人状态。9例患者接受了随访血管造影，5例实现完全闭塞，2例动脉瘤大小缩小，2例因动脉瘤持续存在或增大需要再次治疗。未发生延迟破裂事件。结论：Pipeline血流导向装置对于破裂水泡状动脉瘤是一种技术上可行且有效的治疗方法，尤其适用于病情分级良好且无脑积水的患者。就诊时病情分级较差且需要EVD的患者可能发生出血并发症和预后不良的风险更高。在本系列中，使用单个装置时目标病变未发生再出血。
