Surgical Management of Blood Blister–like Aneurysms of the Internal Carotid Artery

doi:10.1016/j.wneu.2010.06.039

World Neurosurgery

Volume 74, Issues 4–5, October–November 2010, Pages 483-493

https://doi.org/10.1016/j.wneu.2010.06.039 Get rights and content

Objective

To present a review of the literature and a case series of blood blister–like aneurysms (BBA) to show that an adapted direct surgical approach enables treatment of BBA with a low complication rate.

Methods

A retrospective review was performed of patients treated for a ruptured BBA of the internal carotid artery (ICA) at Hôpital Notre-Dame from 2005–2009. Clinicoradiologic data and intraoperative videos were analyzed. Outcome was assessed using the modified Rankin scale (mRS).

Results

This series includes 7 patients (4 women and 3 men) with a mean age of 44.7 (range 30–61). All patients presented with subarachnoid hemorrhage (SAH). Four angiograms were initially negative. Diameter of BBA ranged from 1.1–8.2 mm. No intraoperative or postoperative aneurysm rupture occurred in this series. Although angiograms showed expected mild stenosis of the ICA after clipping, no clinical or radiologic cerebral infarctions were observed. The outcome was favorable in all patients.

Conclusions

Recognition of BBA is essential for proper management. An appropriate neurosurgical strategy has enabled a significant reduction in perioperative aneurysm rupture compared with previous reports and obtains excellent functional results.

Introduction

Blood blister–like aneurysm (BBA) is relatively rare, accounting for 0.3%–1% of intracranial aneurysms and 0.9%–6.5% of aneurysms of the internal carotid artery (ICA). BBA is a hemispheric bulge protruding from nonbranching sites in the supraclinoid portion of the ICA. These aneurysms are located most frequently on the dorsal wall of the ICA, also referred to as the distal medial, superior, or anterior wall of the ICA (26, 33). They are often of small size with a fragile wall and a poorly defined broad-based neck. To date, the natural history of BBA remains unclarified. BBA are known, however, to increase in size and to change configuration into a saccular shape (1, 2, 8, 14, 22). Given the characteristics of BBA, direct clipping is challenging and has been associated with a significant rate of morbidity and mortality. The intraoperative and postoperative rupture rate is higher than the rupture rate observed for saccular aneurysms (19, 26, 32, 33). Although several strategies have been attempted by leading centers across the world, no consensus has been reached on the safest treatment modality because clinical outcome has generally remained poor (23, 26, 28). Technical considerations specific for BBA have been applied in this surgical series. We analyzed the clinical and anatomic characteristics, the surgical steps with their possible pitfalls, and the surgical and functional outcomes in our consecutive series of BBA. Results were evaluated considering previous reported cases of BBA in the English literature.

Section snippets

Clinical Material

Patients with an aneurysmal subarachnoid hemorrhage (SAH) treated between January 2005 and July 2009 were retrospectively reviewed. Cases of BBA were identified from a clinical database of all aneurysms treated surgically by the senior author (M.W.B.). Only patients with BBA of the ICA were included in this study. SAH was diagnosed by computed tomography (CT) scan or lumbar puncture if CT scan was normal. Clinical state was assessed according to the Hunt and Hess (H&H) grading system. Soon

Results

During the study period, seven patients had a ruptured BBA of the ICA (Table 1). Initial angiography was diagnostic in two cases. For one patient, the initial angiogram was doubtful, and the second angiogram clearly showed BBA. For four patients (cases 4–7 in Table 1), the initial angiogram was negative, but a second angiogram documented a BBA. In retrospective, the first angiograms of cases 4, 5, and 7 were suspicious, but these had initially been described as negative.

In our series, no

Discussion

A small sessile aneurysm on the dorsal aspect of the supraclinoid ICA was initially described by Sundt and Murphey (34). These aneurysms were designated as “dorsal ICA aneurysm” by Nakagawa et al. (25). Shigeta et al. (32) introduced the term “blood blister–like aneurysm” to the English literature. BBA are important to recognize given their well-known high intraoperative and postoperative bleeding rate and their potential for regrowth (19, 26, 32, 33). BBA occur most frequently on the dorsal

Conclusions

BBA of the ICA are rare vascular lesions for which reported treatments are associated with a high morbidity rate. Preoperative recognition of BBA is essential for proper management of these aneurysms. This series is a reappraisal of direct clipping as the treatment of choice for BBA in experienced hands. Using an appropriate neurosurgical strategy and adhering to the described technical principles is crucial to reduce perioperative aneurysm rupture and ischemic complications and consequently to

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Cited by (50)

Endovascular treatment of blood blister-like aneurysms of internal carotid artery: Stent-assisted coiling and pipeline flow diversion
2021, Journal of Clinical Neuroscience
To report the stent-assisted coil embolization and flow diversion treatments of blood-blister-like aneurysms based on the theory of acute dissection of the internal carotid artery.
From July 2016 through July 2020, 27 patients presenting with subarachnoid hemorrhage (SAH) due to rupture of internal carotid artery blood blister-like aneurysms were subjected to endovascular treatment with stent-assisted coiling or Pipeline flow diversion. Clinical outcomes were evaluated using modified Rankin Scale score (mRS).
A proximal stenosis caused by angiopathology adjacent to aneurysms were found on internal carotid artery angiograms in all 27 cases. The angiopathology combining with the aneurysms implement that acute dissection of the supraclinoid segment of the internal carotid artery indicated the pathogenesis of blood blister-like aneurysm formation. All aneurysms were treated successfully with alleviation of the adjacent angiopathology after stenting on angiograms. During 1–12 months, mean 3.5 months, complete aneurysm obliteration without adjacent stenosis were found in 25(92.6%) patients. Two (7.4%) cases of recanalization were retreated with complete obliteration at 1 week and 3 months after initial treatment. Clinical mRS 0 and 1 outcomes were observed in 23(85.2%) patients, mRS 2 in 3(11.1%) patients and mRS 6 in 1(3.7%) not related to aneurysm treatment during follow-up.
Acute focal dissection of supraclinoid segment of internal carotid artery underlies the development of blood blister-like aneurysm. Stent-assisted coiling and flow diversion treatments constitute appropriate treatment based on the arterial dissection pathology.
Surgical treatment of intracranial blister aneurysms: A systematic review
2021, Clinical Neurology and Neurosurgery
Intracranial blister aneurysms (BAs) are challenging vascular lesions related to high morbidity and mortality rates. Different surgical and endovascular techniques have been proposed to treat BAs; however, there is no consensus on a preferred treatment.
To systematically review the pertinent literature on clinical and radiological outcomes of different surgical treatments for BAs management, to meta-analyze their clinical and radiological outcomes, and compare these results with those from recent meta-analyses on endovascular treatments for BAs.
The present study was consistently conducted according to the PRISMA guidelines. Five different online medical databases (PubMed, Medline, EMBASE, Scopus, and Web-of-Science) were screened from 2010 through 2020. Papers reporting clinical and radiological outcomes of different surgical treatments for BAs were considered. Event rates were pooled across studies using random-effects meta-analysis.
A total of 35 studies reporting on 514 patients (534 aneurysms) were included. Aneurysm clipping in 223 patients (45.4%; 95% CI 21.9−53.8), bypass and trapping in 87 (17.7%; 95% CI 1.89−21.6), clipping and wrapping in 82 (16.7%; 95% CI 3.71−19.0), and wrapping in 33 (6.7%; 95% CI 0.0−4.87) were the mostly common performed treatments. Complete occlusion rate was reported in 90.7% of patients. The complication rate was as high as 61.1%, the mortality rate was 7.4%, and the mean mRS at follow-up was 2.5.
Our meta-analysis suggests that surgical treatments for BAs are related to higher occlusion, complications and mortality rate than endovascular strategies. However, there is a high-heterogeneity among the included studies and data are poorly reported; so comparing the two type of treatments is unreliable in order to establish which one is better.
Comparison of Bypass and Non–Bypass Surgical Treatments for Internal Carotid Artery Blood Blister-Like Aneurysms: A Meta-Analysis of Efficacy, Safety, and Outcomes
2020, World Neurosurgery
The optimal surgical strategy for treating internal carotid artery (ICA) blood blister-like aneurysms (BBAs) has remained unclear. Although some have preferred bypass surgery, others have favored less-demanding surgical methods. The aim of the present meta-analysis was to assess the efficacy, safety, and outcomes of bypass and non–bypass surgical methods when intended as primary treatment of ICA BBAs.
Studies reporting data on the outcomes of interest for surgically treated patients with ICA BBAs were searched for in the PubMed/MEDLINE, Evidence-Based Medicine Reviews, Cochrane Central, ProQuest, and Scopus databases. The data were analyzed using random effects modeling.
Seven observational studies involving 140 patients met the inclusion criteria. The patients treated with bypass surgery, compared with those treated with non–bypass techniques, had lower odds of poor outcomes (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.28–2.02; P = 0.57; I² = 0%), postoperative vasospasm (OR, 1.73; 95% CI, 0.38–7.92; P = 0.48; I² = 19%), intraoperative bleeding (OR, 3.37; 95% CI, 0.82–13.90; P = 0.09; I² = 0%), postoperative bleeding (OR, 1.91; 95% CI, 0.47–7.76; P = 0.36; I² = 0%), and postoperative recurrence of BBAs (OR, 2.16; 95% CI, 0.54–8.66; P < 0.28; I² = 0%). No comparison, however, achieved statistical significance.
For surgeons who use both bypass and non–bypass surgical strategies, the 2 methods seemed comparable in terms of the outcomes of interest, although the bypass technique appeared superior. However, comparisons with studies reporting bypass as the uniquely preferred technique have indicated that specialization in, and preference for, the bypass procedure has been associated with more favorable outcomes.
Dominance of the Anterior Cerebral Artery as a Predictor of Vasospasm-Related Cerebral Infarction After Surgical Treatment of Ruptured Blood Blister-Like Aneurysm in the Internal Carotid Artery
2019, World Neurosurgery
Vasospasm (VSP)-related ischemic complications have been associated with poor outcomes in patients with subarachnoid hemorrhage due to ruptured blood blister-like aneurysms (BBAs) in the communicating segment of the internal carotid artery (ICA). The purpose of the present study was to investigate the incidence of, and factors related to, VSP-related cerebral infarction (VSP-CI) in patients with surgically treated BBAs in the communicating segment of the ICA.
The medical records of 25 consecutive patients with surgically treated BBAs in the communicating segment of the ICA were reviewed. The preoperative angiographic findings, surgical methods, and patient outcomes, including VSP-CI, were evaluated.
Of the 25 patients, 10 had undergone extracranial–intracranial (EC-IC) bypass with trapping and 15 had undergone clipping surgery. VSP-CI occurred in the ipsilateral hemisphere to the aneurysm in 4 patients with EC-IC bypass with trapping and in 6 patients who had undergone received clipping. Positive balloon test occlusion findings did not affect the occurrence of VSP-CI in the EC-IC bypass and trapping group. The occurrence of VSP-CI was significantly greater in the patients with a dominant anterior cerebral artery ipsilateral to the aneurysm on the preoperative angiogram (P = 0.023), with a hazard ratio of 14.14 (95% confidence interval, 1.57–127.68).
The results of preoperative balloon test occlusion were less reliable for predicting postoperative ischemic complications of EC-IC bypass with trapping in patients with ruptured BBAs in the communicating segment of the ICA. However, anterior cerebral artery dominance ipsilateral to the ruptured aneurysm could be predictive for postoperative VSP-CI.
Microsurgical Management of Ruptured Blood Blister Aneurysms of the Internal Carotid Artery without Bypass: A Retrospective Single-Center Study of 36 Patients over 20 Years
2019, World Neurosurgery
Microsurgical management of blood blister aneurysms of the internal carotid artery is challenging because of the special characteristics of these aneurysms. We reviewed our diverse surgical methods with long-term clinical and radiologic follow-up.
We retrospectively reviewed all patients with blood blister aneurysms presenting with subarachnoid hemorrhage that were treated with microsurgical obliteration between 1993 and 2017. Baseline characteristics of patients and aneurysms, surgical methods, and clinical and radiologic outcomes were analyzed.
This study included 36 patients. The patients were treated using microsurgery with direct clipping (2 patients; 5.6%), cotton-assisted clipping (24 patients; 66.7%), wrapping-clipping (5 patients; 13.9%), or wrapping-clipping with suturing (5 patients; 13.9%). Complete occlusion of aneurysm was achieved in 34 of 36 patients (94.4%). Severe vasospasm developed in 18 of 36 patients (50%). Ischemic events occurred in 8 patients (22.2%), 2 of whom remained with severe disability. Regrowth or recurrence occurred in 1 patient (0.28%), which required additional stent-assisted coil embolization. Mean modified Rankin Scale score was 2.0 (median, 1.0; range, 0–4) at discharge and 1.3 (median, 1.0; range, 0–4) at the last follow-up.
Direct clipping is ideal if possible; however, direct clipping is challenging in most blood blister aneurysms. Assisted clipping with cotton is mainly used and could be an effective technique for reinforcement of the friable wall, with good clinical outcomes in our series. Moreover, suturing followed by wrapping-clipping is also useful for managing intraoperative rupture.
Concomitant ruptured anterior circulation and unruptured posterior circulation aneurysms: Treatment strategy and review of literature
2019, Journal of Clinical Neuroscience
Basilar artery apex or bifurcation is the most common location for aneurysms arising from posterior cerebral circulation. Reports of unruptured aneurysms of the basilar bifurcation associated with ruptured anterior circulation aneurysms are rare. The presence of multiple intracranial aneurysms poses a significantly high risk to management than a single aneurysm due several factors involved. Surgical management is considered the best treatment modality for most aneurysmal types and location with quite a few limitations when applicable. Authors have conducted a literature review of anterior and posterior circulation concomitant aneurysms and report their own experience with a case of anterior communicating artery blister type aneurysmal rupture presented with the symptoms and signs of subarachnoid hemorrhage concomitant with an unruptured basilar artery bifurcation aneurysm. Moreover, the anomalous origin of thalamoperforators at the basilar apex instead of the posterior cerebral artery makes it reasonably challenging for the microsurgical clipping. Discussed is the clinical presentation, radiological studies obtained, surgical approach utilized with an adequate exposure of the entire circle of Willis as well as the critical decision making when managing these challenging cases.

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Peer-Review ReportSurgical Management of Blood Blister–like Aneurysms of the Internal Carotid Artery

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Clinical Material

Results

Discussion

Conclusions

J Clin Neurosci

J Clin Neurosci

Surg Neurol

J Clin Neurosci

Surg Neurol

J Clin Neurosci

J Clin Neurosci

J Clin Neurosci

Blood blister-like aneurysms of the internal carotid artery

J Neurosurg

Blister-like aneurysms of the anterior communicating artery: a retrospective review of diagnosis and treatment in five patients

Neurosurgery

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

Neurosurg Focus

Ideal internal carotid artery trapping technique without bypass in a patient with insufficient collateral flow

J Korean Neurosurg Soc

Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms

Neurosurgery

Angiographic documentation of de novo aneurysm—case report

Neurol Med Chir (Tokyo)

Pathological consideration of a “blister-like” aneurysm at the superior wall of the internal carotid artery: case report

Neurosurgery

Successful staged treatment for ruptured blister-like dissecting aneurysm of the intracranial internal carotid artery: acute GDC embolization for the blister-like aneurysm followed by proximal occlusion with extracranial-intracranial bypass in the chronic stage

Minim Invasive Neurosurg

Treatment of blood blister-like aneurysm of the internal carotid artery with stent-assisted coil embolization followed by stent-within-a-stent technique: case report

J Neurosurg

Primary treatment of ruptured blood blister-like aneurysms with stent-assisted coil embolization: report of two cases

Acta Radiol

Wrap-clipping with polytetrafluoroethylene for ruptured blisterlike aneurysms of the internal carotid arteryTechnical note

Neurosurgery

New method for obliterative treatment of an anterior wall aneurysm in the internal carotid artery: encircling silicone sheet clip procedure—technical case report

Neurosurgery

Reconstructive endovascular treatment of ruptured blood blister-like aneurysms of the internal carotid artery

J Neurosurg

Peer-Review Report
Surgical Management of Blood Blister–like Aneurysms of the Internal Carotid Artery