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Dissecting Pseudoaneurysms and Blister Aneurysms

  • Amgad El Mekabaty
  • Gabor Toth
  • Dheeraj Gandhi
  • Alexander Coon
  • Ferdinand K. Hui
Chapter

Abstract

In contrast to “true” aneurysms, which have walls that contain intima, media, and adventitia, “false” or pseudoaneurysms no longer have all layers of the normal mural components. The precise mechanisms of pseudoaneurysm formation remain unclear but are believed to result either from a tear of the intima with blood dissecting into the wall or rupture of vasa vasorum. The classic angiographic appearance of a dissecting pseudoaneurysm is a fusiform dilatation with or without adjacent stenosis. Once ruptured there is a high rate of re-rupture during the first week. Symptomatic, ruptured or large pseudoaneurysms warrant treatment. Depending on the location of the pseudoaneurysm and clinical scenario, deconstructive or reconstructive approaches can be utilized, while endovascular reconstructive techniques are more commonly employed for intracranial lesions.

“Blister” aneurysms are rare, fragile pseudoaneurysms with a high risk of re-rupture as well as rupture during treatment. Flow diversion appears to be emerging as a preferred method for treatment of these aneurysms, offering a higher rate of occlusion with decreased risk of iatrogenic rupture.

Keywords

Dissecting pseudoaneurysms Blister aneurysms Coiling Flow diversion Aneurysms, blister Pseudoaneurysms 

References

  1. 1.
    E. GL. Medial defects in the circle of willis and their relation to aneurysm formation. J Pathol Bacteriol. 1940;51(2):169–316.CrossRefGoogle Scholar
  2. 2.
    Mitchell GM, McCann JJ, Rogers IW, Hickey MJ, Morrison WA, O’Brien BM. A morphological study of the long-term repair process in experimentally stretched but unruptured arteries and veins. Br J Plast Surg. 1996;49(1):34–40.PubMedCrossRefGoogle Scholar
  3. 3.
    W.E. S. Pathology of the Cerebral Blood Vessels. St. Louis: C.V. Mosby; 1972.Google Scholar
  4. 4.
    Mizutani T, Kojima H, Asamoto S. Healing process for cerebral dissecting aneurysms presenting with subarachnoid hemorrhage. Neurosurgery. 2004;54(2):342–7. discussion 347–348.PubMedCrossRefGoogle Scholar
  5. 5.
    Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001;344(12):898–906.PubMedCrossRefGoogle Scholar
  6. 6.
    Fusco MR, Harrigan MR. Cerebrovascular dissections – a review part I: spontaneous dissections. Neurosurgery. 2011;68(1):242–57. discussion 257.PubMedCrossRefGoogle Scholar
  7. 7.
    Fusco MR, Harrigan MR. Cerebrovascular dissections: a review. Part II: blunt cerebrovascular injury. Neurosurgery. 2011;68(2):517–30. discussion 530.PubMedCrossRefGoogle Scholar
  8. 8.
    Paraskevas KI, Batchelder AJ, Naylor AR. Fate of distal false aneurysms complicating internal carotid artery dissection: a systematic review. Eur J Vasc Endovasc Surg. 2016;52(3):281–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Lasjaunias P, Ter Brugge KG, Berenstein A. Surgical neuroangiography, vol. 2.1/2.2. Switzerland: Springer; 2004.Google Scholar
  10. 10.
    Mizutani T, Miki Y, Kojima H, Suzuki H. Proposed classification of nonatherosclerotic cerebral fusiform and dissecting aneurysms. Neurosurgery. 1999;45(2):253–9. discussion 259–260.PubMedCrossRefGoogle Scholar
  11. 11.
    Yamaura I, Tani E, Yokota M, Nakano A, Fukami M, Kaba K, Matsumoto T. Endovascular treatment of ruptured dissecting aneurysms aimed at occlusion of the dissected site by using Guglielmi detachable coils. J Neurosurg. 1999;90(5):853–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Mizutani T, Aruga T, Kirino T, Miki Y, Saito I, Tsuchida T. Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery. 1995;36(5):905–11. discussion 912-903.PubMedCrossRefGoogle Scholar
  13. 13.
    Poole JC, Cromwell SB, Benditt EP. Behavior of smooth muscle cells and formation of extracellular structures in the reaction of arterial walls to injury. Am J Pathol. 1971;62(3):391–414.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Droste DW, Junker K, Stögbauer F, Lowens S, Besselmann M, Braun B, Ringelstein EB. Clinically silent circulating microemboli in 20 patients with carotid or vertebral artery dissection. Cerebrovasc Dis. 2001;12(3):181–5.PubMedCrossRefGoogle Scholar
  15. 15.
    Srinivasan J, Newell DW, Sturzenegger M, Mayberg MR, Winn HR. Transcranial Doppler in the evaluation of internal carotid artery dissection. Stroke. 1996;27(7):1226–30.PubMedCrossRefGoogle Scholar
  16. 16.
    Daou B, Hammer C, Chalouhi N, Starke RM, Jabbour P, Rosenwasser RH, Tjoumakaris S. Dissecting pseudoaneurysms: predictors of symptom occurrence, enlargement, clinical outcome, and treatment. J Neurosurg. 2016;125(4):936–42.PubMedCrossRefGoogle Scholar
  17. 17.
    Mokri B, Piepgras DG, Houser OW. Traumatic dissections of the extracranial internal carotid artery. J Neurosurg. 1988;68(2):189–97.PubMedCrossRefGoogle Scholar
  18. 18.
    Yamaura A. Diagnosis and treatment of vertebral aneurysms. J Neurosurg. 1988;69(3):345–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Flemming KD, Wiebers DO, Brown RD, Link MJ, Nakatomi H, Huston J, McClelland R, Christianson TJ. Prospective risk of hemorrhage in patients with vertebrobasilar nonsaccular intracranial aneurysm. J Neurosurg. 2004;101(1):82–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Kobayashi N, Murayama Y, Yuki I, Ishibashi T, Ebara M, Arakawa H, Irie K, Takao H, Kajiwara I, Nishimura K, et al. Natural course of dissecting vertebrobasilar artery aneurysms without stroke. AJNR Am J Neuroradiol. 2014;35(7):1371–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Kim BM, Kim SH, Kim DI, Shin YS, Suh SH, Kim DJ, Park SI, Park KY, Ahn SS. Outcomes and prognostic factors of intracranial unruptured vertebrobasilar artery dissection. Neurology. 2011;76(20):1735–41.PubMedCrossRefGoogle Scholar
  22. 22.
    Madaelil TP, Wallace AN, Chatterjee AN, Zipfel GJ, Dacey RG, Cross DT, Moran CJ, Derdeyn CP. Endovascular parent vessel sacrifice in ruptured dissecting vertebral and posterior inferior cerebellar artery aneurysms: clinical outcomes and review of the literature. J Neurointerv Surg. 2016;8(8):796–801.PubMedCrossRefGoogle Scholar
  23. 23.
    Lv X, Jiang C, Li Y, Wu Z. Clinical outcomes of ruptured and unruptured vertebral artery-posterior inferior cerebellar artery complex dissecting aneurysms after endovascular embolization. AJNR Am J Neuroradiol. 2010;31(7):1232–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Sugiu K, Tokunaga K, Watanabe K, Sasahara W, Ono S, Tamiya T, Date I. Emergent endovascular treatment of ruptured vertebral artery dissecting aneurysms. Neuroradiology. 2005;47(2):158–64.PubMedCrossRefGoogle Scholar
  25. 25.
    Ducruet AF, Crowley RW, Albuquerque FC, McDougall CG. Reconstructive endovascular treatment of a ruptured vertebral artery dissecting aneurysm using the Pipeline embolization device. J Neurointerv Surg. 2013;5(4):e20.PubMedCrossRefGoogle Scholar
  26. 26.
    Narata AP, Yilmaz H, Schaller K, Lovblad KO, Pereira VM. Flow-diverting stent for ruptured intracranial dissecting aneurysm of vertebral artery. Neurosurgery. 2012;70(4):982–8. discussion 988–989.PubMedCrossRefGoogle Scholar
  27. 27.
    McTaggart RA, Santarelli JG, Marcellus ML, Steinberg GK, Dodd RL, Do HM, Marks MP. Delayed retraction of the pipeline embolization device and corking failure: pitfalls of pipeline embolization device placement in the setting of a ruptured aneurysm. Neurosurgery. 2013;72(2 Suppl Operative):onsE245–50. discussion onsE250-241.PubMedGoogle Scholar
  28. 28.
    Munich SA, Tan LA, Keigher KM, Chen M, Moftakhar R, Lopes DK. The pipeline embolization device for the treatment of posterior circulation fusiform aneurysms: lessons learned at a single institution. J Neurosurg. 2014;121(5):1077–84.PubMedCrossRefGoogle Scholar
  29. 29.
    Mandell DM, Mossa-Basha M, Qiao Y, Hess CP, Hui F, Matouk C, Johnson MH, Daemen MJ, Vossough A, Edjlali M, et al. Intracranial vessel wall MRI: Principles and expert consensus recommendations of the American Society of Neuroradiology. AJNR Am J Neuroradiol. 2017;38(2):218–29. doi:10.3174/ajnr.A4893. Epub 2016 Jul 28.PubMedCrossRefGoogle Scholar
  30. 30.
    Fox B, Humphries WE, Doss VT, Hoit D, Elijovich L, Arthur AS. Rupture of giant vertebrobasilar aneurysm following flow diversion: mechanical stretch as a potential mechanism for early aneurysm rupture. BMJ Case Rep. 2014;2014Google Scholar
  31. 31.
    Hernández-Durán S, Ogilvy CS. Clinical outcomes of patients with vertebral artery dissection treated endovascularly: a meta-analysis. Neurosurg Rev. 2014;37(4):569–77.PubMedCrossRefGoogle Scholar
  32. 32.
    Park PJ, Meyer FB. The Sundt clip graft. Neurosurgery. 2010;66(6 Suppl Operative):300–5. discussion 305.PubMedGoogle Scholar
  33. 33.
    Jafar JJ, Kamiryo T, Chiles BW, Nelson PK. A dissecting aneurysm of the posteroinferior cerebellar artery: case report. Neurosurgery. 1998;43(2):353–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Hirao J, Okamoto H, Watanabe T, Asano S, Teraoka A. Dissecting aneurysms at the A1 segment of the anterior cerebral artery – two case reports. Neurol Med Chir (Tokyo). 2001;41(5):271–8.CrossRefGoogle Scholar
  35. 35.
    Ohkuma H, Suzuki S, Kikkawa T, Shimamura N. Neuroradiologic and clinical features of arterial dissection of the anterior cerebral artery. AJNR Am J Neuroradiol. 2003;24(4):691–9.PubMedGoogle Scholar
  36. 36.
    Zhu W, Liu P, Tian Y, Gu Y, Xu B, Chen L, Zhou L, Mao Y. Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies. Acta Neurochir. 2013;155(8):1481–91.PubMedCrossRefGoogle Scholar
  37. 37.
    Hensler J, Jensen-Kondering U, Ulmer S, Jansen O. Spontaneous dissections of the anterior cerebral artery: a meta-analysis of the literature and three recent cases. Neuroradiology. 2016;58:997.PubMedCrossRefGoogle Scholar
  38. 38.
    Chaves C, Estol C, Esnaola MM, Gorson K, O’Donoghue M, De Witt LD, Caplan LR. Spontaneous intracranial internal carotid artery dissection: report of 10 patients. Arch Neurol. 2002;59(6):977–81.PubMedCrossRefGoogle Scholar
  39. 39.
    Thines L, Zairi F, Taschner C, Leclerc X, Lucas C, Bourgeois P, Lejeune JP. Subarachnoid hemorrhage from spontaneous dissection of the anterior cerebral artery. Cerebrovasc Dis. 2006;22(5–6):452–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Mehta B, Burke T, Kole M, Bydon A, Seyfried D, Malik G. Stent-within-a-stent technique for the treatment of dissecting vertebral artery aneurysms. AJNR Am J Neuroradiol. 2003;24(9):1814–8.PubMedGoogle Scholar
  41. 41.
    Ahn JY, Han IB, Kim TG, Yoon PH, Lee YJ, Lee BH, Seo SH, Kim DI, Hong CK, Joo JY. Endovascular treatment of intracranial vertebral artery dissections with stent placement or stent-assisted coiling. AJNR Am J Neuroradiol. 2006;27(7):1514–20.PubMedGoogle Scholar
  42. 42.
    Ahn JY, Chung SS, Lee BH, Kim SH, Yoon PH, Joo JY, Kim JK. Treatment of spontaneous arterial dissections with stent placement for preservation of the parent artery. Acta Neurochir. 2005;147(3):265–73. discussion 273.PubMedCrossRefGoogle Scholar
  43. 43.
    Lylyk P, Cohen JE, Ceratto R, Ferrario A, Miranda C. Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils. J Neurosurg. 2001;94(3):427–32.PubMedCrossRefGoogle Scholar
  44. 44.
    Lanzino G, Wakhloo AK, Fessler RD, Hartney ML, Guterman LR, Hopkins LN. Efficacy and current limitations of intravascular stents for intracranial internal carotid, vertebral, and basilar artery aneurysms. J Neurosurg. 1999;91(4):538–46.PubMedCrossRefGoogle Scholar
  45. 45.
    Byoun HS, Yi HJ, Choi KS, Chun HJ, Ko Y, Bak KH. Comparison of endovascular treatments of ruptured dissecting aneurysms of the intracranial internal carotid artery and vertebral artery with a review of the literature. J Korean Neurosurg Soc. 2016;59(5):449–57.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Lee VH, Brown RD, Mandrekar JN, Mokri B. Incidence and outcome of cervical artery dissection: a population-based study. Neurology. 2006;67(10):1809–12.PubMedCrossRefGoogle Scholar
  47. 47.
    Béjot Y, Daubail B, Debette S, Durier J, Giroud M. Incidence and outcome of cerebrovascular events related to cervical artery dissection: the Dijon Stroke Registry. Int J Stroke. 2014;9(7):879–82.PubMedCrossRefGoogle Scholar
  48. 48.
    Guillon B, Brunereau L, Biousse V, Djouhri H, Lévy C, Bousser MG. Long-term follow-up of aneurysms developed during extracranial internal carotid artery dissection. Neurology. 1999;53(1):117–22.PubMedCrossRefGoogle Scholar
  49. 49.
    Touzé E, Randoux B, Méary E, Arquizan C, Meder JF, Mas JL. Aneurysmal forms of cervical artery dissection: associated factors and outcome. Stroke. 2001;32(2):418–23.PubMedCrossRefGoogle Scholar
  50. 50.
    Djouhri H, Guillon B, Brunereau L, Lévy C, Bousson V, Biousse V, Arrivé L, Tubiana JM. MR angiography for the long-term follow-up of dissecting aneurysms of the extracranial internal carotid artery. AJR Am J Roentgenol. 2000;174(4):1137–40.PubMedCrossRefGoogle Scholar
  51. 51.
    Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, Noorollah LD, Panagos PD, Schievink WI, Schwartz NE, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke. 2014;45(10):3155–74.PubMedCrossRefGoogle Scholar
  52. 52.
    Moon K, Albuquerque F, Cole TS, Gross BA, McDougall CG. 355 endovascular management of cervical carotid and vertebral artery dissection: indications, techniques, and outcomes from a 20-year experience. Neurosurgery. 2016;63(Suppl 1):205.CrossRefGoogle Scholar
  53. 53.
    Horowitz MB, Purdy PD. The use of stents in the management of neurovascular disease: a review of historical and present status. Neurosurgery. 2000;46(6):1335–42. discussion 1342–1333.PubMedCrossRefGoogle Scholar
  54. 54.
    Linfante I, Mayich M, Sonig A, Fujimoto J, Siddiqui A, Dabus G. Flow diversion with pipeline embolic device as treatment of subarachnoid hemorrhage secondary to blister aneurysms: dual-center experience and review of the literature. J Neurointerv Surg. 2017;9(1):29–33.PubMedCrossRefGoogle Scholar
  55. 55.
    Griessenauer CJ, Ogilvy CS, Foreman PM, Chua MH, Harrigan MR, He L, Fusco MR, Mocco JD, Stapleton CJ, Patel AB, et al. Pipeline embolization device for small intracranial aneurysms: evaluation of safety and efficacy in a multicenter cohort. Neurosurgery. 2017;105:232–7.Google Scholar
  56. 56.
    Ogawa A, Suzuki M, Ogasawara K. Aneurysms at nonbranching sites in the surpaclinoid portion of the internal carotid artery: internal carotid artery trunk aneurysms. Neurosurgery. 2000;47(3):578–83. discussion 583-576.PubMedGoogle Scholar
  57. 57.
    Ahn JY, Cho JH, Jung JY, Lee BH, Yoon PH. Blister-like aneurysms of the supraclinoid internal carotid artery: challenging endovascular treatment with stent-assisted coiling. J Clin Neurosci. 2008;15(9):1058–61.PubMedCrossRefGoogle Scholar
  58. 58.
    McLaughlin N, Laroche M, Bojanowski MW. Blister-like aneurysms of the internal carotid artery – management considerations. Neurochirurgie. 2012;58(2–3):170–86.PubMedCrossRefGoogle Scholar
  59. 59.
    Rouchaud A, Brinjikji W, Cloft HJ, Kallmes DF. Endovascular treatment of ruptured blister-like aneurysms: a systematic review and meta-analysis with focus on deconstructive versus reconstructive and flow-diverter treatments. AJNR Am J Neuroradiol. 2015;36(12):2331–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Yu J, Xu B, Guo Y, Xu K. Direct clipping of a blister-like aneurysm in the supraclinoid segment of the internal carotid artery: a clinical analysis of nine cases. Int J Clin Exp Med. 2015;8(11):21786–95.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Owen CM, Montemurro N, Lawton MT. Blister aneurysms of the internal carotid artery: microsurgical results and management strategy. Neurosurgery. 2017;80(2):235–47.PubMedGoogle Scholar
  62. 62.
    Pahl FH, de Oliveira MF, MeQ TG, Capel Cardoso AC, Rotta JM. Blister-like aneurysms: report of successful surgical treatment of consecutive cases and review of the literature. World Neurosurg. 2016;89:376–81.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Amgad El Mekabaty
    • 1
    • 2
  • Gabor Toth
    • 3
  • Dheeraj Gandhi
    • 4
  • Alexander Coon
    • 5
  • Ferdinand K. Hui
    • 6
    • 7
    • 8
  1. 1.Department of Radiology and Radiological SciencesJohns Hopkins HospitalBaltimoreUSA
  2. 2.Department of Radiology and Radiological SciencesUniversity Hospital of BaselBaselSwitzerland
  3. 3.Cerebrovascular Center, Cleveland Clinic Lerner College of MedicineMayfield HeightsUSA
  4. 4.Departments of Diagnostic Radiology and Nuclear Medicine, Neurology and NeurosurgeryCenter of Metabolic Imaging and Therapeutics and Executive Committee Member for the Comprehensive Stroke Center, Johns Hopkins HospitalBaltimoreUSA
  5. 5.Departments of Neurosurgery, Neurology, and RadiologyJohns Hopkins University School of Medicine, The Johns Hopkins HospitalBaltimoreUSA
  6. 6.Department of Radiology and Radiological ScienceJohns Hopkins HospitalBaltimoreUSA
  7. 7.Carey School of Business, Johns Hopkins UniversityBaltimoreUSA
  8. 8.Department of Interventional StrokeJohns Hopkins National Capital RegionBaltimoreUSA

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