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

Long-term follow up of surgical management of blood blister-like aneurysms at non-branching sites of the internal carotid artery

To describe long-term follow-up of 25 patients who presented with subarachnoid hemorrhages due to blood blister-like aneurysms (BBAs) treated with direct clipping or clip reinforcement with or without direct neck repair. Between June 1993 and July 2009, 25 consecutive patients with ruptured BBAs of the supraclinoid internal carotid artery were retrospectively reviewed. The mean age of patients was 39.5 ± 11.3 years. The mean duration of clinical follow-up was 128.9 months (range, 85-196 months). All aneurysms were located in the supraclinoid portion of the internal carotid artery. The mean aneurysm diameter was 4.04 ± 1.3 mm on intra-operative microscopic field. Tearing of the aneurysmal neck during dissection occurred in 8 (32%) patients. Six of 7 patients with neck tearing underwent direct neck repair. Surgeons treated aneurysms via direct clipping with a Bemsheet® in 5 (20%) patients or by clip reinforcement with a silicone sheet in 20 (80%) patients. Clinical outcomes were favorable (modified Rankin Scale [mRS]: 0-2) in 21 (84%) of 25 patients. Four (16%) patients had an unfavorable outcome (mRS: 3-6). The patient with severe disability (mRS: 4) was treated with clip reinforcement and direct neck repair. Mild stenosis, moderate stenosis, and total occlusion of the parent artery were confirmed in 10 (40%) patients, 6 (24%) patients, and 1 (4%) patient, respectively. Although surgical treatment of BBAs was associated with varying degrees of parent vessel patency loss, long-term follow-up results for more than 10 years showed that direct surgical clipping or clip reinforcement with a silicone sheet appeared to be a curative surgery.

Flow Diverter Device-Assisted Coiling Treatment for Cerebral Blister Aneurysm: A Single-Center Study

Although endovascular treatment is a promising approach, blood blister-like aneurysms (BBAs) still present treatment challenges. This study aimed to assess the effectiveness and safety of flow diverter device-assisted coiling (FDDAC) for the treatment of BBAs, which are broad based and friable with a high rebleeding risk. Eight patients (five females and three males) who presented with subarachnoid hemorrhages (SAH) due to BBA ruptures between May 2020 and May 2022 were retrospectively enrolled. All patients were treated by flow diverter device (Tubridge) adjunctive coil embolization using a semi-deploying technique. The demographic information, angiographic data, interval between admission and treatment, materials, therapy, clinical outcomes (including periprocedural and intraprocedural mortality and morbidity), and follow-up results of all patients were reviewed. The mean age of the patients with BBAs was 48.5 years (range 31–62 years); aneurysm sizes ranged from 2.2 × 1.7 mm to 4.6 × 3.2 mm, and the median Hunt–Hess score was 3. All aneurysms were completely closed at follow-up, and all 8 patients had excellent clinical outcomes (modified Rankin scores = 0–2) at discharge. Angiograms showed complete aneurysm occlusion after 6 months to 1 year. In addition, there were no cases of re-rupture, re-treatment, or recurrence of the aneurysms. FDDAC is safe to use in patients with BBAs and provides an alternative treatment option for this disease.

A Patient with a Ruptured Blood Blister-like Aneurysm of the Internal Carotid Artery in Whom Two LVIS Stents Were Inserted

Objective

We report a case in which multiple overlapping low-profile visualized intraluminal support (LVIS) stents were used as monotherapy for ruptured blood blister-like aneurysm (BBA) of the internal carotid artery (ICA).

Case Presentation

A 48-year-old female presented to the emergency room with acute-onset headache. She was alert without neurological deficit with subarachnoid hemorrhage (SAH) Hunt and Kosnik grade I. Emergency angiography revealed a BBA from the supraclinoid ICA. This aneurysm had a small diameter, which makes coil embolization difficult. Therefore, we planned to use multiple overlapping LVIS stents as monotherapy for the ruptured aneurysm. The postoperative course was uneventful without rebleeding. The patient exhibited no neurological deficits on the clinical follow-up at 1 year.

Conclusion

Multiple overlapping LVIS stents as monotherapy is useful for ruptured BBAs of the ICA.

Stent-assisted coiling for the treatment of ruptured micro-intracranial wide-necked aneurysms

The stent-assisted coil embolization technique has been increasingly used in the clinic, but its efficacy and safety have yet to be assessed. This study aimed to evaluate the efficacy and safety of stent-assisted coiling in the treatment of micro-intracranial wide-necked aneurysms. Between May 2007 and November 2011, a total of 35 micro-intracranial wide-necked ruptured aneurysms were occluded with Enterprise stent-assisted coils. The patients were followed up for two years. Stent-assisted coiling was performed successfully in all cases, and stent placement was satisfactory without any complications. Of 35 aneurysms, 13 (37.1%) were completely occluded, ten (28.5%) had residual necks, and 12 (34.2%) had residual aneurysms. In the two-year follow-up, no aneurysm rupture occurred and no patients had nerve dysfunction. All patients were reviewed by digital subtraction angiography or computed tomography angiography. One patient had a residual neck (2.8%), and no patients experienced stent restenosis or thromboembolic events. In general, stent-assisted coiling is effective and safe for the treatment of micro-intracranial wide-necked aneurysms.

The Blood Blister Like-aneurysm: Usefulness of Sundt Clip

Objective

Blood blister-like aneurysm (BBA) is a kind of dorsal wall aneurysm and it is small, sessile, fragile and hazardous because of its high mortality and morbidity. Many challenges tried to establish the management or strategy. But so far, there is no optimal treatment of choice for the BBA. In this article, 17 cases of the ruptured BBA in one institute were analyzed retrospectively. The operative options were correlated with surgical and clinical outcomes.

Materials and Methods

During 14 years between October, 2002 and October, 2016, 23 patients were treated for subarachnoid hemorrhage with ruptured dorsal wall aneurysms. There were various strategies for treatment and different outcomes revealed. BBA were 17 (74%) cases and 6 (26%) cases were saccular aneurysm. By excluding saccular aneurysm, BBA was sorted and classified with its morphological characteristics, and the outcome of treatment in each case investigated retrospectively.

Results

Among 17 BBA-cases, 8 cases get microsurgical operation by Sundt clip. 5 cases get operation by conventional Yasargil clip, 1 case treated by Yasargil clip with wrapping, and 2 cases underwent endovascular management with coiling, and 1 case was managed by endovascular trapping of involved internal cerebral artery. Clinical outcomes were analyzed with modified Rankin Scale, Glasgow outcome scale and post-operative complications.

Conclusion

As the optimal management, operation using Sundt clip had much significance in treatment BBA. And, a thorough analysis of the angiography is essential to prepare for the treatment of BBA.

Nontraumatic, posterior circulation pseudoaneurysm of the basilar artery summit with complete spontaneous resolution: Case report and literature review

Background:

Intracranial pseudoaneurysms are rare vascular defects of arterial walls that are classically the result of traumatic injury, iatrogenic causes, or infection. Idiopathic pseudoaneurysms are seen even less frequently and are often related to atherosclerosis. Pseudoaneurysms are most commonly found along the distal wall of the internal carotid artery, however, can occur at any location in the cerebrovascular circulation. Treatment of these arterial defects is often challenging due to their frail nature.

Case Description:

A 61-year-old male with a history of hypertension presented with a severe, atypical headache without history of trauma. Computed tomography (CT) and computed tomography angiography (CTA) demonstrated diffuse subarachnoid hemorrhage. Imaging demonstrated a 3.5 mm pseudoaneurysm projecting distally from the basilar artery at the apex. Repeated imaging (CTA, digital subtraction angiography) demonstrated decreased size and flow associated within the aneurysm over the following 2 weeks; as such, the patient was managed conservatively. The patient was discharged in neurologically intact condition when imaging at 14 days confirmed complete and spontaneous resolution of the pseudoaneurysm.

Conclusion:

Idiopathic pseudoaneurysms that are commonly associated with atherosclerosis are most commonly managed surgically or endovascularly. Conservative approach may be considered in a select group of patients that exhibit decreased size and/or flow within the aneurysm in repeated imaging; spontaneous resolution was seen in the present case.

Microsurgical versus endovascular interventions for blood-blister aneurysms of the internal carotid artery: systematic review of literature and meta-analysis on safety and efficacy

OBJECTIVE Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) have a poor natural history associated with high morbidity and mortality. Currently, both surgical and endovascular techniques are employed to treat BBAs; thus, the authors sought to perform a meta-analysis to compare the efficacy and safety of these approaches. METHODS A literature search of PubMed, MEDLINE, and Google Scholar online databases was performed to include pertinent English-language studies from 2005 to 2015 that discussed the efficacy and safety of either surgical or endovascular therapies to treat BBAs. RESULTS Thirty-six papers describing 256 patients with BBAs treated endovascularly (122 procedures) or surgically (139 procedures) were examined for data related to therapeutic efficacy and safety. Pooled analysis of 9 papers demonstrated immediate and late (mean 20.9 months) aneurysm occlusion rates of 88.9% (95% CI 77.6%-94.8%) and 88.4% (95% CI 76.7%-94.6%), respectively, in surgically treated patients. Pooled analysis of 12 papers revealed immediate and late aneurysm obliteration rates of 63.9% (95% CI 52.3%-74.1%) and 75.9% (95% CI 65.9%-83.7%), respectively, in endovascularly treated aneurysms. Procedure-related complications and overall poor neurological outcomes were slightly greater in the surgically treated cases than in the endovascularly treated cases (27.8% [95% CI 19.6%-37.8%] vs 26.2% [95% CI 18.4%-35.8%]), indicating that endovascular therapy may provide better outcomes. CONCLUSIONS Blood-blister aneurysms are rare, challenging lesions with a poor prognosis. Although surgical management potentially offers superior aneurysm obliteration rates immediately after treatment and at the long-term follow-up, endovascular therapy may have a better safety profile and provide better functional outcomes than surgery. A registry of patients treated for BBAs may be warranted to better document the natural course of the disease as well as treatment outcomes.

Current status of the treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery: A review

Currently, the treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) is challenging and utilizes many therapeutic methods, including direct clipping and suturing, clipping after wrapping, clipping after suturing, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass. In these therapeutic approaches, the optimal treatment method for BBAs has not yet been defined based on the current understanding of BBAs of the supraclinoid ICA. Therefore, in this study, we aimed to review the literature from PubMed to discuss and analyze the pros and cons of the above approaches while adding our own viewpoints to the discussion. Among the surgical methods, direct clipping was the easiest method if the compensation of the collateral circulation of the intracranial distal ICA was sufficient or direct clipping did not induce stenosis in the parent artery. In addition, the clipping after wrapping technique should be chosen as the optimal surgical modality to prevent rebleeding from these lesions. Among the endovascular methods, multiple overlapping stents (≥3) with coils may be a feasible alternative for the treatment of ruptured BBAs. In addition, flow-diverting stents appear to have a higher rate of complete occlusion and a lower rate of retreatment and are a promising treatment method. Finally, when all treatments failed or the compensation of the collateral circulation of the intracranial distal ICA was insufficient, the extracranial-intracranial (EC-IC) arterial bypass associated with surgical or endovascular trapping, a complex and highly dangerous method, was used as the treatment of last resort.

Solitaire AB Stent-Assisted Coiling of Wide-Neck Micro Aneurysms

Objective

Solitaire AB stent-assisted coiling facilitates the endovascular treatment of wide-necked intracranial aneurysms. We present our experience of coiling the micro-aneurysms of wide-neck with Solitaire AB stent assisting in a single center.

Methods

Thirty-one Solitaire AB stents were used to treat via endovascular approach patients with 31 wide-neck micro aneurysms in a single center in China. Technical and clinical complications were recorded. Modified Rankin Scale was used to evaluate the patients' conditions via clinic and telephone follow-up.

Results

The mean width of aneurysm sac was 2.30±0.42 mm, and the mean diameter of aneurysm neck was 2.83±0.48 mm. Complete occlusion was achieved in 28 aneurysms (90.32%); neck remnant was seen in 3 aneurysms (9.68%). Technical and clinical complications related to the procedure were encountered in four patients (12.5%). Two patients died (6.25%). No patient had a permanent deficit.

Conclusion

Solitaire AB stent was a safe and efficiency tool in assisting coiling of micro aneurysms with wide neck, but may be not suitable for a blaster-like one. Mid- and long-term follow-up will be required to elucidate the impact of the Solitaire AB stent on recanalization rate.

Morphological aspects of blister aneurysms and nuances for surgical treatment

OBJECT

Blister aneurysms of the supraclinoid part of the internal carotid artery (ICA) are known for their high morbidity and mortality rates related to treatment, regardless of whether the treatment is surgical or endovascular. However, this grim prognosis is based on results that indiscriminately group all blister aneurysms together without taking into account the heterogeneous appearance of these lesions. The goal of this study was 2-fold: to determine whether different blister aneurysm morphologies present different pitfalls, which would then require different surgical strategies, as well as to determine whether there are identifiable subgroups of these types of aneurysms based on morphology.

METHODS

The authors reviewed the charts, cerebral catheter angiograms, surgical reports, and intraoperative videos of all ICA blister aneurysms treated surgically at the Centre Hospitalier de l'Université de Montréal from 2005 to 2012 to investigate whether there was a relationship between morphology and pitfalls, and whether different surgical strategies had been used according to these pitfalls. During this review process the authors noted 4 distinct morphological aspects. These 4 aspects led to a review of the English and French literature on blister aneurysms in which imaging was available, to determine whether other cases could also be classified into the same 4 subgroups based on these morphological aspects.

RESULTS

The retrospective review of the authors' series of 10 patients allowed a division into 4 distinct subtypes: Type I (classic), Type II (berry-like), Type III (longitudinal), and Type IV (circumferential). These subtypes may at times be progressive stages in the arterial anomaly, and could represent a continuum. Each subtype described in this paper presented its own pitfalls and required specific surgical adaptations. Upon reviewing the literature the authors retained 35 studies involving a total of 61 cases of blister aneurysms, and all cases were able to be classified into 1 of these 4 distinct subtypes.

CONCLUSIONS

Although they share some common characteristics, blister aneurysms may be divided into distinct subtypes, suggestive of a continuum. Such a classification with a detailed description of each type of blister aneurysm would allow for better recognition to anticipate complications during intervention and better assess the different treatment strategies according to the subtypes.

Endovascular management of intracranial blister aneurysms: spectrum and limitations of contemporary techniques

Background

Intracranial blister aneurysms are rare lesions that are notoriously more difficult to treat than typical saccular aneurysms. High complication rates associated with surgery have sparked considerable interest in endovascular techniques, though not well-studied, to treat blister aneurysms.

Objective

To evaluate our experience using various endovascular approaches to treat blister aneurysms.

Methods

All consecutive blister aneurysms treated using an endovascular approach by the study authors over a 3-year period were retrospectively analyzed. A literature review was also performed.

Results

Nine patients with blister aneurysms underwent 11 endovascular interventions. In various combinations, stents were used in 8/11, coils in 5/11, and Onyx in 3/11 procedures. At mean angiographic follow-up of 200 days, 8/9 aneurysms were completely occluded by endovascular means alone requiring no further treatment and 1/9 aneurysms required surgical bypass/trapping after one failed surgical and two failed endovascular treatments. At mean clinical follow-up of 416 days, modified Rankin Scale scores were improved in six patients, stable in two, and worsened in one patient. One complication occurred in 11 procedures (9%), resulting in a permanent neurologic deficit. No unintended endovascular parent vessel sacrifice, intraprocedural aneurysmal ruptures, antiplatelet-related complications, post-treatment aneurysmal re-ruptures, or deaths occurred.

Conclusion

This series highlights both the spectrum and limitations of endovascular techniques currently used to treat blister aneurysms, including a novel application of stent-assisted Onyx embolization. Long-term follow-up and experience in larger studies are required to better define the role of endovascular therapy in the management of these difficult lesions.

Blister-like aneurysms of middle cerebral artery: a multicenter retrospective review of diagnosis and treatment in three patients

Blood blister-like aneurysms (BBA) were described for the first time in the 1990s, as small hemispherical bulges arising from a very fragile arterial wall. Until 2008, it was thought that this type of aneurysm almost exclusively affected the internal carotid artery, in particular, its dorsal portion. Subsequently, it was discovered that a BBA may also be present on the anterior communicating artery and on the vessels of the posterior cranial fossa. However, we found no reports in English-language literature of BBA arising from the middle cerebral artery (MCA). In this article, we present three cases of MCA BBA and discuss the unique diagnostic and therapeutic aspects of this vascular lesion. In our retrospective, multicenter review of 1330 patients with non-traumatic subarachnoid hemorrhage admitted to our services from 2000 to 2013, we found three cases (all in men) of MCA BBA. The patients' outcome was assessed using the modified Rankin scale. All three patients underwent angio-computed tomography, which did not reveal any aneurysms. Digital subtraction angiography performed within 24-48 h after admission, in all cases, demonstrated a very small aneurysm (<2 mm), with a triangular shape and abroad base, at non-branching sites of MCA. All the aneurysms were treated: one by wrapping + clipping, one by wrapping + flow-diverter stent, and one with coils. At the time of surgery, the aneurysms appeared on the surface of the parent artery without any involvement of the branches. All presented as blister-like aneurysms that were thin-walled and lacked a surgical neck. At the time of discharge, the outcome was good in one patient and poor in the other two. Our cases demonstrate that BBA can also arise from the MCA, despite the lack of previous reports of this occurrence; a BBA should be suspected, particularly in cases of non-perimesencephalic subarachnoid hemorrhage in which the presence of a MCA aneurysm is suspected but not revealed by digital subtraction angiography or angio-computed tomography.

Endovascular exclusion of the anterior communicating artery with flow-diverter stents as an emergency treatment for blister-like intracranial aneurysms. A case report

Blood blister-like aneurysms (BLAs) are rare lesions, associated with diffuse subarachnoid hemorrhage (SAH). BLAs tend to rebleed quickly after first bleeding and must be treated as an emergency. Acute treatment is challenging using surgical and endovascular approaches due to the fragile aneurysm wall and small sac. Flow-diverter stents (FDSs) may offer a new option for the treatment of difficult small aneurysms. We describe a case of a ruptured BLA on the anterior communicating artery (AComA) treated in the acute phase of SAH by endovascular exclusion of the AComA with deployment of two FDSs in the A1/A2 junctions of both anterior cerebral arteries (ACAs). A 61-year-old man was admitted for diffuse SAH with a focal interhemispheric hematoma. Angiography revealed multiple arterial wall irregularities on the AComA and both ACAs. We performed an endovascular shunt of the AComA by deploying two FDSs in both A1/A2 junctions. Immediate control injections confirmed flow diversion in the A1/A2 segments of the ACAs with decreased blood flow in the AComA. The patient's course in hospital was uneventful. A three-month follow-up angiogram confirmed complete exclusion of the aneurysms, complete exclusion of the AComA, and patency of the two ACAs without any persistent arterial wall irregularity. Endovascular bypass using an FDS for a ruptured BLA has never been described. It establishes a new therapeutic option despite the need for antiplatelet therapy. Endovascular AComA exclusion using an FDS may be a solution when no other treatment is available for a ruptured BLA.

The pipeline flow-diverting stent for exclusion of ruptured intracranial aneurysms with difficult morphologies

BACKGROUND

The Pipeline Embolization Device (PED) is a flow-diverting stent that may represent a new therapeutic tool for difficult-to-treat intracranial aneurysms, including those that present with subarachnoid hemorrhage (SAH).

OBJECTIVE

To demonstrate the feasibility of utilizing the PED as a primary treatment for ruptured aneurysms with challenging morphologies.

METHODS

Three patients with ruptured intracranial aneurysms presented with SAH. Three distinct and difficult-to-treat aneurysm morphologies were encountered: (1) a small basilar trunk pseudoaneurysm, (2) a carotid artery blister aneurysm, and (3) an A1/A2 junction-dissecting-type aneurysm. All were treated with deployment of one or more PEDs across the aneurysm.

RESULTS

PEDs were successfully deployed in all 3 cases. Two patients were treated with 2 overlapping PEDs, and the third patient was treated with a single device. Aneurysm obliteration was achieved in all 3 cases with no early rehemorrhage or other clinically adverse event.

CONCLUSION

Endovascular treatment with the pipeline flow-diverting stent may be a viable treatment option for otherwise difficult-to-treat aneurysm morphologies in the context of acute SAH.

Blister-like aneurysms of the internal carotid artery - management considerations

Blood blister-like aneurysms (BBA) originate at non-branching sites of the internal carotid artery (ICA). These aneurysms present a fragile wall and a poorly defined broad-based neck. Recognition of the BBA is essential for proper management of these vascular lesions. Various surgical and endovascular strategies have been attempted for these heterogeneous lesions. These have been associated with significant morbidity and mortality including rebleeding, regrowth, ischemic and thromboembolic complications. The authors review the key elements important for diagnosis and management of BBA and review current treatment options.

Staged treatment of a blood blister-like aneurysm with stent-assisted coiling followed by flow diverter in-stent insertion. A case report

Blood blister-like aneurysms (BBLA) are rare lesions sometimes difficult to recognize and in most cases associated with diffuse subarachnoid haemorrhage and severe clinical conditions. BBLA are life-threatening because they tend to enlarge rapidly and to rebleed, and no consensus has so far been reached on the best management strategy. We describe a patient with a BBLA in the right ICA treated successful by a two-stage embolization procedure first with coils and an open cell stent (Neuroform 3) and later by further coil placement and insertion of a flow-diverting stent (Silk).

Acute endovascular treatment (< 48 hours) of uncoilable ruptured aneurysms at non-branching sites using silk flow-diverting devices

A blood blister-like (BBL) or dissecting aneurysm should be carefully considered if located at a non-branching site of the supra-clinoid internal carotid artery (ICA). Several surgical and endovascular treatment methods have been proposed but they all carry a relatively high risk of morbidity and mortality. This study evaluated the effectiveness of a novel Silk flow-diverting device (SFD) placed in the early acute stage. Three patients presenting with acute subarachnoid haemorrhage caused by small blister-like aneurysms of the carotid siphon were treated within 48 hours after admission by placement of SFDs. More than one device was placed to cover the lesion. None of the patients were premedicated and started anti-platelet therapy during the procedure. All aneurysms were successfully occluded. A good outcome was observed in two out of three treated patients. No thromboembolic or haemorrhagic event occurred during or after the procedures, or during follow-up (6-14 months). SFD prevented rebleeding and the use of these devices could be proposed as an option to treat fragile uncoilable BBL aneurysms, even in the early acute phase without anti-platelet premedication. Larger studies and long-terms results are necessary.

Endovascular coil embolization for saccular-shaped blood blister-like aneurysms of the internal carotid artery

BACKGROUND

Because of their fragile and thin wall, ruptured blood blister-like aneurysms (BBAs) at the anterior wall of the internal carotid artery (ICA) are difficult to manage, both surgically, as well as endovascularly. BBA is usually a tiny and broad-necked aneurysm, but it occasionally demonstrates a relatively saccular-like shape. In addition, the pseudoaneurysm sac often assumes a saccular shape. In this paper, the authors present their experience in treating these saccular-shaped BBAs endovascularly with coil packing.

METHOD

Nine saccular-shaped ruptured BBAs in nine patients (one male and eight females; mean age 51.3 years, range 38-76) were treated with coil packing of the lesion between January 2006 and August 2010 in Nagoya University and its affiliated hospitals. Clinical, procedural, and angiographic data were retrospectively evaluated.

FINDINGS

Seven BBAs were treated by balloon-assisted coil embolization. Two remaining BBAs were embolized without balloon inflation, though a balloon catheter was on standby at the ICA. In one case, in which a saccular coil embolization could not be achieved, ICA trapping was performed. Three (33.3%) were treated in acute, two (22.2%) in subacute, and four (44.4%) in chronic period. One (11.1%) intraoperative rupture occurred. Six (66.7%) had excellent clinical outcomes, while two (22.2%) proved fatal outcomes. During the follow-up period (mean 18.9 months, range 4-48), two out of seven (28.6%) aneurysms presented an angiographical recurrence, but both were treated by coil embolization without complications. The remaining five (71.4%) aneurysms were completely resolved.

CONCLUSIONS

Endovascular coil embolization can be considered as an alternative treatment option for selective saccular-shaped BBAs.

Surgical management of blood blister-like aneurysms of the internal carotid artery

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.

The Sundt clip graft

BACKGROUND

The Sundt clip graft is a vessel-encircling clip that can be used to repair a significant dehiscence or tear in an intracerebral vessel wall during urgent situations.

OBJECTIVE

This article analyzes the use of the Sundt clip in a variety of acute intraoperative situations.

METHODS

Under institutional review board (IRB) approval, a retrospective review of surgical records from 1988 to 2008 was conducted to identify patients in whom the clip graft was used. These patients' medical records and radiographic imaging studies were reviewed and analyzed.

RESULTS

Seventeen patients were identified. A variety of vascular wall dehiscences were treated, including 9 with carotid aneurysm blisters. Other vessels repaired included the anterior choroidal artery (ACA), posterior communicating artery (PCA), and middle cerebral artery (MCA). Most were repaired with a 5-to 6-mm clip graft in varying lengths. Postoperative angiography was performed in 16 patients. In 14 patients, the vessel was preserved with a patency of 80% or greater. One patient had a 50% stenosis, and in another the vessel was occluded. The neurologic outcome was related to the underlying pathology and clinical presentation. Overall, 13 patients recovered with a Glasgow Outcome Score (GOS) of 5. Three patients did poorly, with a GOS of 3, and 1 patient died related to subarachnoid hemorrhage (SAH) vasospasm.

CONCLUSION

Neurosurgeons should remember that the Sundt clip graft may be used in emergent situations in which a vascular tear or blister is encountered and the vessel cannot be repaired with suturing or other techniques, including standard encircling aneurysm clips.

Endovascular treatment of a ruptured blood blister-like aneurysm with a flow-diverting stent

Treatment of BBAs is currently challenging and remains difficult despite improvement of microsurgical technique and advancement in endovascular technologies. Therapeutic options are reconstructive and deconstructive open surgeries or endovascular procedures. However, there is a lack of consensus about optimal treatment. We report a case of 38-year old woman with subarachnoid hemorrhage due to a ruptured BBA successfully treated with placement of an endovascular flow-diverting stent.

Semi-jailing technique for coil embolization of complex, wide-necked intracranial aneurysms

OBJECTIVE

Stent-assisted coiling of intracranial aneurysms is performed by placing a microcatheter through a stent's interstices or jailing the microcatheter between the stent and the artery. Both approaches impede manipulation of the microcatheter during coiling. We describe a modified jailing technique that improves catheter maneuverability and report the safety and efficacy of the method for the treatment of complex, wide-necked aneurysms.

METHODS

The semi-jailing technique involves the partial deployment of a retrievable stent, bridging part of the aneurysm neck while leaving space to maneuver the microcatheter. Twenty-two complex, wide-necked aneurysms, including 3 ruptured and 5 dissecting, were treated using the semi-jailing technique (15 women; mean age, 55.2 years).

RESULTS

The semi-jailing technique was successfully applied in all cases. Immediate posttreatment angiograms showed total occlusion of the aneurysm in 17 cases (77%), neck remnant in 3 cases (14%), and aneurysm dome filling in 2 cases (9%). Follow-up angiography available in 10 patients at an average of 8.5 months showed progressive occlusion in 1 aneurysm and 7 remained occluded. In 2 cases of dissecting aneurysms, retreatment was required. No permanent periprocedural morbidity was encountered. One patient died of complications secondary to intracranial hemorrhage 6 days after treatment. In 2 cases (9%), thromboembolic events after final stent placement were successfully treated with intraarterial thrombolysis. No delayed stent migration was seen.

CONCLUSION

Semi-jailing is a safe and effective stent-assisted coiling technique that facilitates treatment of complex, wide-necked aneurysms.

Ideal Internal Carotid Artery Trapping Technique without Bypass in a Patient with Insufficient Collateral Flow

Internal carotid artery (ICA) trapping can be used for treating intracranial giant aneurysm, blood blister-like aneurysms and ICA rupture during the surgery. We present a novel ICA trapping technique which can be used with insufficient collaterals flow via anterior communicating artery (AcoA) and posterior communicating artery (PcoA). A patient was admitted with severe headache and the cerebral angiography demonstrated a typical blood blister-like aneurysm at the contralateral side of PcoA. For trapping the aneurysm, the first clip was placed at the ICA just proximal to the aneurysm whereas the distal clip was placed obliquely proximal to the origin of the PcoA to preserve blood flow from the PcoA to the distal ICA. The patient was completely recovered with good collaterals filling to the right ICA territories via AcoA and PcoA. This technique may be an effective treatment option for trapping the aneurysm, especially when the PcoA preservation is mandatory.