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Feasibility and Safety of Pipeline Embolization Device in Patients With Ruptured Carotid Blister Aneurysms

Yoon, Jang W. MD, MS*; Siddiqui, Adnan H. MD; Dumont, Travis M. MD‡,§; Levy, Elad I. MD; Hopkins, L. Nelson MD; Lanzino, Giuseppe MD; Lopes, Demetrius K. MD; Moftakhar, Roham MD; Billingsley, Joshua T. MD; Welch, Babu G. MD#; Boulos, Alan S. MD**; Yamamoto, Junichi MD, PhD**; Tawk, Rabih G. MD*; Ringer, Andrew J. MD‡‡; Hanel, Ricardo A. MD, PhD*,§§; for the Endovascular Neurosurgery Research Group

doi: 10.1227/NEU.0000000000000487
Research-Human-Clinical Studies

BACKGROUND: Treatment of internal carotid ruptured blister aneurysms (IC-RBA) presents many challenges to neurosurgeons because of the high propensity for rebleeding during intervention. The role of a Pipeline Embolization Device (PED) in the treatment of this challenging aneurysm subtype remains undefined despite theoretical advantages.

OBJECTIVE: To present a series of 11 patients treated with a PED and to discuss the management and results of this novel application of flow diverters.

METHODS: Medical records of patients who presented with IC-RBA from May 2011 to March 2013 were retrospectively reviewed at 6 institutions in the United States. All relevant data were independently compiled.

RESULTS: A total of 12 IC-RBAs in 11 patients were treated during the study period. Nine (75%) were treated with a single PED; 1 was treated with 2 PEDs; 1 was treated with coils and 1 PED; and 1 was treated with coils and 2 PEDs. Three (27%) had major perioperative complications: middle cerebral artery territory infarction, vision loss, and death. Seven patients demonstrated complete obliteration of the aneurysm in postoperative imaging. Early clinical outcomes were favorable (modified Rankin Scale score, 0-2) in all 10 survivors.

CONCLUSION: This study demonstrates the feasibility and safety of using the PED to treat IC-RBA with fair initial results. The proper introduction and management of antiplatelet regimen are key for successful results. Bleeding complications related to dual antiplatelet therapy were similar to those in previous studies of stent-assisted coiling for the same population. Larger cohort analysis is needed to define the precise role of flow diverters in the treatment of IC-RBA.

ABBREVIATIONS: ICA, internal carotid artery

mRS, modified Rankin Scale

PED, Pipeline Embolization Device

PFT, platelet function testing

PUFS, Pipeline for Uncoilable or Failed Aneurysms

*Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida;

Department of Neurosurgery, University of Buffalo Medical Center, Buffalo, New York;

§Department of Surgery, Division of Neurosurgery, University of Arizona, Tucson, Arizona (work was conducted while at the University of Buffalo Medical Center, Buffalo, New York);

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;

Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois;

#Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas;

**Department of Neurosurgery, Albany Medical Center, Albany, New York;

‡‡Department of Neurosurgery, University of Cincinnati Medical Center, Cincinnati, Ohio;

§§Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida

Correspondence: Ricardo A. Hanel, MD, PhD, Baptist Health System, 800 Prudential Dr, Tower B, 11th Floor, Jacksonville, FL 32207. E-mail:

Received December 19, 2013

Accepted May 28, 2014

Copyright © by the Congress of Neurological Surgeons