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Treatment of blood blister aneurysms of the internal carotid artery with flow diversion
  1. Maxim Mokin1,
  2. Angel Chinea1,
  3. Christopher T Primiani1,
  4. Zeguang Ren1,
  5. Peter Kan2,
  6. Visish M Srinivasan2,
  7. Ricardo Hanel3,
  8. Pedro Aguilar-Salinas3,
  9. Aquilla S Turk4,
  10. Raymond D Turner4,
  11. M Imran Chaudry4,
  12. Andrew J Ringer5,
  13. Babu G Welch6,
  14. Vitor Mendes Pereira7,
  15. Leonardo Renieri7,
  16. Mariangela Piano8,
  17. Lucas Elijovich9,
  18. Adam S Arthur9,
  19. Ahmed Cheema9,
  20. Demetrius Klee Lopes10,
  21. Ahmed Saied10,
  22. Blaise W Baxter11,
  23. Harris Hawk11,
  24. Ajit S Puri12,
  25. Ajay K Wakhloo12,
  26. Hussain Shallwani13,
  27. Elad I Levy13,
  28. Adnan H Siddiqui13,
  29. Guilherme Dabus14,
  30. Italo Linfante14
  1. 1 Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
  2. 2 Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
  3. 3 Department of Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
  4. 4 Medical University of South Carolina, Charleston, South Carolina, USA
  5. 5 Department of Neurosurgery, Mayfield Clinic, University of Cincinnati, Cincinnati, Ohio, USA
  6. 6 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
  7. 7 Division of Neuroradiology, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
  8. 8 Department of Neuroradiology, Grande Ospedale Metropolitano Niguarda, Milano, Italy
  9. 9 Semmes-Murphey Neurologic and Spine Institute, Semmes-Murphey Clinic, Memphis, Tennessee, USA
  10. 10 Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
  11. 11 Department of Radiology, University of Tennessee, Erlanger Hospital, Knoxville, Tennessee, USA
  12. 12 Department of Radiology, University of Massachusetts, Worcester, Massachusetts, USA
  13. 13 Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA
  14. 14 Miami Cardiac and Vascular Institute, Baptist Hospital, Miami, Florida, USA
  1. Correspondence to Dr Maxim Mokin, Department of Neurosurgery, University of South Florida, Tampa, FL 33620, USA; mokin{at}


Background Blood blister aneurysms (BBA) are a rare subset of intracranial aneurysms that represent a therapeutic challenge from both a surgical and endovascular perspective.

Objective To report multicenter experience with flow diversion exclusively for BBA, located at non-branching segments along the anteromedial wall of the supraclinoidal internal carotid artery (ICA).

Methods Consecutive cases of BBA located at non-branching segments along the anteromedial wall of the supraclinoidal ICA treated with flow diversion were included in the final analysis.

Results 49 patients with 51 BBA of the ICA treated with devices to achieve the flow diversion effect were identified. 43 patients with 45 BBA of the ICA were treated with the pipeline embolization device and were included in the final analysis. Angiographic follow-up data were available for 30 patients (32 aneurysms in total); 87.5% of aneurysms (28/32) showed complete obliteration, 9.4% (3/32) showed reduced filling, and 3.1% (1/32) persistent filling. There was no difference between the size of aneurysm (≤2 mm vs >2 mm) or the use of adjunct coiling and complete occlusion of the aneurysm on follow-up (P=0.354 and P=0.865, respectively). Clinical follow-up data were available for 38 of 43 patients. 68% of patients (26/38) had a good clinical outcome (modified Rankin scale score of 0–2) at 3 months. There were 7 (16%) immediate procedural and 2 (5%) delayed complications, with 1 case of fatal delayed re-rupture after the initial treatment.

Conclusions Our data support the use of a flow diversion technique as a safe and effective therapeutic modality for BBA of the supraclinoid ICA.

  • aneurysm
  • flow diverter
  • subarachnoid

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  • Contributors MM and IL: study concept and design. MM and AC: wrote the manuscript. MM and CTP: statistical analysis. All authors participated in data collection and analysis, edited the manuscript, and approved the final version.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests ASA: consultant for Covidien, Johnson and Johnson, Siemens, Stryker, and Terumo; grants from Siemens and Terumo. BWB: personal fees from Penumbra Inc, Stryker, Medtronic, Route 92 Medical, and Pulsar. MIC: consultant for Penumbra, Medtronic, Microvention, Codman, Pulsar Vascular, Q’Apel, Rebound Medical, and Blockade Medical. GD: consultant for Proctor; speakers bureau for Medtronic and Microvention; shareholder in Medina Medical, InNeuroCo, and Stryker/Surpass. LE: consultant for Stryker Neurovascular, Microvention, and Codman Neurovascular. RH: consultant for Covidien, Stryker, Codman, and MicroVention. PK: consultant for Stryker Neurovascular, Covidien, and MicroVention. EIL: shareholder/ownership interests in Intratech Medical Ltd, Blockade Medical LLC, and Medina Medical; principal investigator in Covidien US SWIFT PRIME Trials; honoraria for training and lecturing from Covidien; consultant for Pulsar, Medina Medical, and Blockade Medical; other financial support from Abbott for carotid training for physicians. IL: consultant and speaker bureau for Covidien, Codman, and Stryker. DKL: consultant for Covidien and Stryker; shareholder/ownership in Penumbra and Blockade Medical; advisory board for Siemens; principal investigator for Liberty Trial (Penumbra). VMP: consultant for Medtronic, Stryker, Penumbra, and BALT; research grant from Philips. MM: consultant for Toshiba (Canon) Medical. ASP: consultant for Medtronic Neurovascular and Stryker Neurovascular; research grants from Medtronic Neurovascular and Stryker Neurovascular. AJR: consultant for Stryker, MicroVention, and Covidien/ev3. AHS: grants from National Institutes of Health/NINDS/NIBIB, University at Buffalo–none related to present study; financial interests in Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, and Lazarus Effect; consultant for Codman & Shurtleff Inc, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra, Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, and Blockade Medical; speakers bureau for Codman & Shurtleff Inc; National Steering Committee for Penumbra Inc 3D Separator Trial, Covidien SWIFT PRIME trial, and MicroVention FRED trial; advisory boards for Codman & Shurtleff and Covidien Neurovascular; honoraria from Abbott Vascular, Codman & Shurtleff, and Penumbra Inc. AST: consultant for Stryker, Codman, Penumbra, and Microvention; research grants (not related to the present study) from Stryker, Codman, Micorvention, Penumbra, and Covidien; financial interests in Medina Medical, Lazarus Effect, Pulsar Vascular, and Blockade Medical. RDT: consultant for Penumbra, Medtronic, Microvention, Codman, Pulsar Vascular, Q’Apel, Rebound Medical, and Blockade Medical. AKW: consultant for Stryker Neurovascular; research grants from Philips Healthcare, and Wyss Institute; speaker for Harvard Postgraduate Course and Miami Cardiovascular Institute. BGW: consultant for Stryker and Medtronic.

  • Ethics approval The study was approved by the institutional review board at each participating institution.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data were presented in this study.