Surgical treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery with extracranial-intracranial bypass and trapping

Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA.
Neurosurgical FOCUS (Impact Factor: 2.11). 02/2008; 24(2):E13. DOI: 10.3171/FOC/2008/24/2/E13
Source: PubMed


Blood blister-like aneurysms (BBAs) arise from the supraclinoid internal carotid artery (ICA) at non-branching sites. These aneurysms are challenging to treat primarily with either surgical clip placement or endovascular therapy. The authors describe a series of 4 patients who presented with high-grade subarachnoid hemorrhage (SAH) due to a BBA, which was treated with an extracranial-intracranial (EC-IC) bypass followed by trapping of the aneurysm.
Four patients presented with SAH due to a BBA of the ICA. Three of these patients were treated with an endovascular procedure; following the vasospasm period, definitive treatment with EC-IC bypass followed by trapping of the aneurysmal parent vessel was performed.
Two of the patients who were treated endovascularly suffered rebleeding prior to bypass and trapping. Three of the 4 patients had a good outcome (modified Rankin Scale Score 1 or 2), and 1 patient who suffered 2 episodes of rebleeding died.
Treatment of BBAs of the ICA remains difficult, particularly in the setting of high-grade SAH. Patients with this challenging condition often require multiple procedures and have a high incidence of rebleeding. Definitive treatment of these aneurysms consists of EC-IC bypass and surgical or endovascular trapping.

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    • "For pseudoaneurysm and hemorrhagic dissection, surgical or endovascular trapping of the parent artery may be the most definite means to prevent rebleeding so long as there is sufficient collateral cross-flow. BBAs were reported to have been successfully treated by endovascular or surgical trapping [9] [11]. But the ischemic complication is still the problem. "
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    ABSTRACT: Objectives: Blood blister-like aneurysms (BBAs) are aneurysms arising from the nonbranching arterial trunk, which are usually small and located at the anterior wall of supraclinoid internal carotid artery. These aneurysms are quite dangerous due to their fragile neck. This paper aims to evaluate the application of stent-assisted coil embolization in the treatment of BBAs. Methods: A retrospective review of the aneurysm database in our institution identified 8 patients carrying BBAs planned to be treated by stent-assisted coil embolization. The clinical characteristics, angiographic outcome, and follow-up results were reviewed. Results: Stent-assisted coil embolization was successfully performed in 5 cases (62.5%). Two procedures were treated with sole stent deployment (25%). One patient suffered intra-operative rupture (12.5%) and endovascular trapping was performed. The modified Rankin scale (mRs) score in living patients at discharge was 1 in four cases, 2 in one case, and 3 in one case. Two patients died of post-operative hemorrhage (25%). The mRs score at 9-36 months' follow-up was 0 in four cases, 1 in one case, and 2 in one case. All patients were followed up angiographically, and regrowth was observed in three patients, who accepted further endovascular treatments. Conclusion: Stent-assisted coil embolization may probably reduce the mortality, but may not be a cure for all BBAs.
    Clinical neurology and neurosurgery 10/2012; 115(7). DOI:10.1016/j.clineuro.2012.09.022 · 1.13 Impact Factor
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    ABSTRACT: Blister-like aneurysms are small hemispherical bulges that usually originate from the anteromedial wall of the distal internal carotid artery and cause significant subarachnoid hemorrhage. It is very important to recognize this novel lesion as a different type of aneurysm than ordinary berry aneurysms. We report the case of a 43-year-old man who underwent a diagnostic procedure and was awaiting surgery elsewhere before being transferred to our institution. A right sided blister-like aneurysm was seen on angiograms. Although the aneurysm bled intraoperatively, 2 clips were placed with one slightly catching the medial artery wall. The outcome was excellent. Since blister-like aneurysms are different than saccular aneurysms both morphologically and histologically, their treatment also differs making surgical exploration and standard clipping a more hazardous situation than usual. In fact, surgical decision for blister aneurysms should be individual with alternative plans in case the initial treatment strategy fails. Such a flexible strategy also necessitates preoperative cerebrovascular flow testing and a variety of additional hardware like encircling graft clips, microsutures or wrapping material ready in the operating room on top of traditional aneurysm clips.
    Turkish neurosurgery 02/2008; 18(4):439-45. · 0.58 Impact Factor
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    ABSTRACT: Ruptured aneurysms located at the non-branching sites of the internal carotid artery, including blister-like aneurysms, possess unique clinical and technical features. This report presents nine consecutively managed patients with these types of aneurysm, detailing the clinical and radiological characteristics and surgical outcomes. The initial angiography identified aneurysmal lesions in six of the nine patients with two of these patients requiring additional three-dimensional (3D) angiography. In three patients the aneurysm was only diagnosed on second or third angiograms. Six patients had blister-like aneurysms, and two had saccular-shaped aneurysms diagnosed on the basis of intraoperative findings. One patient with a saccular aneurysm died without surgery. Eight patients underwent a microsurgical procedure: clipping in five, clipping on wrapping with suturing in two and trapping in one. Three of these eight patients had an intraoperative rupture. A favorable outcome was obtained in seven patients. Advances in microsurgical techniques to prevent premature rupture and 3D radiological diagnosis with careful pre-operative consideration of the surgical strategies will be required for a further improvement of the clinical outcome.
    Journal of Clinical Neuroscience 05/2009; 16(8):1018-23. DOI:10.1016/j.jocn.2008.05.025 · 1.38 Impact Factor
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