Endovascular Parent Artery Reconstruction for Ruptured Intracranial Blister Aneurysms: Demonstrating Safety and Efficacy After Early Flow Diversion.

BACKGROUND: Ruptured blister aneurysms are rare lesions that exhibit more aggressive behavior as compared to saccular aneurysms. Among all the endovascular treatment options, flow diversion seems to be showing the most promising results. Controversies regarding the optimal timing of flow diversion (early or delayed), along with the use and safety of dual antiplatelets, remain and are yet to be standardized. OBJECTIVE: The objective of this study was to assess the safety and efficacy of early endovascular flow diversion (within 72 hours) in ruptured intracranial blister aneurysms, specifically looking at the bleeding risk and treatment benefit of a standard DAPT regimen. METHODS: This study involved a retrospective analysis of patients with ruptured intracranial blister aneurysms at a tertiary care hospital in Mumbai, India (February 2017 - December 2022). All patients treated with endovascular embolization using a flow diverter device (FDD) within the first three days after rupture were included. A standard dual antiplatelet therapy (DAPT) protocol was used to prevent thromboembolic complications. Outcomes measured included complete angiographic obliteration and clinical outcome, mRS ≤2. RESULTS: Mean age was 58 (14 ± 8.36) years, and 57% (12/21) were women. The follow-up ranged from 12 to 30 months (mean 16.6 months). Out of 21 patients, 18 (85.7%) had immediate intraoperative stasis in the aneurysmal sac, with an immediate occlusion rate of 42.8% and complete obliteration in 19 (90.5%) patients at six months follow-up. Two patients (9.5%) developed intraluminal thrombus, which was managed successfully with rescue tirofiban, leading to a 0% rate of procedural mortality or further embolic issues. The DAPT protocol did not lead to any cases of re-rupture or bleeding complications. All patients reached sustained functional independence, gauged by a modified Rankin Scale score of 0 to 2, at the final follow-up, which had a mean duration of 16.6 months. CONCLUSION: The concept of endoluminal parent artery reconstruction using a flow diverter device is promising for the treatment of ruptured intracranial blister aneurysms. Early flow diversion combined with strong clinical data from this series shows that a DAPT regimen is safe and necessary in this emergency situation, successfully reducing thromboembolic problems without immediately increasing the risk of hemorrhagic sequelae.