Bleb Embolization of Ruptured Cerebral Aneurysms with Coils and n-Butyl Cyanoacrylate Following Proximal Flow Control: Two Case Reports

Objective: Morphologically challenging cerebral aneurysms cannot be treated through standard endovascular procedures. We report two cases of ruptured aneurysms treated using coils and n-butyl cyanoacrylate (NBCA).Case Presentations: Case 1 was an 80-year-old woman diagnosed with a subarachnoid hemorrhage (SAH). An angiogram revealed a large and wide-necked basilar artery bifurcation aneurysm. Bilateral superior cerebellar and posterior cerebral arteries (PCAs) originated from the aneurysmal wall. A 3-mm-diameter bleb was detected on the aneurysmal fundus. The bleb enlarged 1 month following coil insertion. During the second treatment, we infused a small volume of 33% NBCA into the coil-framed bleb following proximal flow control of the bilateral vertebral arteries (VAs). The complete bleb obliteration was confirmed by the angiogram at 6 months later. The coil shape was followed up via plane X-ray for 5 years. No rebleeding occurred. Case 2 was a 41-year-old woman diagnosed with SAH. An angiogram revealed a dissecting aneurysm of the left PCA (P1 and P2 segments) accompanying a bleb on the P1 segment. Endovascular treatment was performed, and a coil was inserted into the bleb, infusing 33% NBCA into the coil frame following proximal flow control of bilateral VAs and the right internal carotid artery. Angiograms conducted at 3 months, 1 year, and 9 years and an MRA conducted 12 years later revealed a lack of bleb recanalization.Conclusion: We developed a Coil and NBCA technique to obliterate ruptured blebs following proximal flow control. This technique can be considered an effective alternative for treating morphologically challenging cerebral aneurysms.