Rupture of aneurysms following balloon embolization

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✓ Three cases of complex aneurysms are presented in which balloon embolization therapy was associated with subsequent aneurysmal rupture, causing subarachnoid hemorrhage in two cases and a carotid-cavernous fistula in one. Two of these patients were treated directly by balloon embolization following surgical exploration. The third patient developed the fistula during postembolization volume expansion and heparinization.

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Address reprint requests to: Allan J. Fox, M.D., Diagnostic Radiology, University Hospital, Box 5339, London, Ontario N6A 5A5, Canada.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. a: Left carotid angiogram, anteroposterior projection, showing a large ruptured carotid aneurysm with fusiform origin from the carotid artery. b: Postoperative angiogram. Three aneurysm clips are discernible (arrows) and the medial aspect of the aneurysm still fills. c: Postembolization angiogram showing the aneurysm lumen occluded with a single detachable balloon (small arrows). A small remnant of residual neck (curved arrow) can be seen filling prior to reversal of heparin. d: Postembolization plain radiograph demonstrating the balloon in relation to the aneurysm clips.

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    Case 1. a: Plain radiograph 2 days postembolization showing that the balloon has shifted medially and superiorly outside the original limits of the aneurysm. b: Angiogram following hemorrhage. The aneurysm lumen is seen to be refilling and the balloon was migrated medially and superiorly outside the original limits of the aneurysm wall. c: Angiogram 6 months following stenosis established with a Selverstone clamp showing almost complete obliteration of the aneurysm.

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    Case 2. a: Left carotid angiogram, lateral projection, showing a large unruptured cavernous carotid aneurysm. b: Plain radiograph showing the position of the three detached balloons. Note the silver clips in the balloon tips projecting beyond the balloon margins. c: Postembolization angiogram. The internal carotid artery is preserved and the aneurysm is eliminated from the cerebral circulation by three intra-aneurysmal balloons (arrows). d: Angiogram 4 days postembolization showing a carotid-cavernous sinus fistula. The balloons and silver clips are clearly visible and do not appear to have shifted.

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    Case 3. a and b: Right (a) and left (b) vertebral artery angiograms, anteroposterior projection, showing a giant 3-cm aneurysm apparently arising from the right vertebrobasilar junction. The posterior inferior cerebellar artery (PICA) is seen proximal to the origin of the aneurysm bilaterally (arrows). c and d: Left vertebral artery angiograms, early (c) and late (d) phases, after surgical clipping of the right vertebral artery distal to the PICA and after the embolization procedure. The silver clip within the balloon tip is seen in two different positions (arrows) within the aneurysm lumen, demonstrating that the balloon was freely floating within the aneurysm. e: Left vertebral angiogram after aneurysm rupture. The silver clip in the balloon is clearly seen outside the aneurysm lumen (arrow).

References

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