J Cerebrovasc Endovasc Neurosurg.  2012 Jun;14(2):99-103. 10.7461/jcen.2012.14.2.99.

Salvage Surgical Treatment for Failed Endovascular Procedure of a Blood Blister-Like Aneurysm

• Cho TG
• Hwang SN
• Nam TK
• Park SW

• KMID: 1808444
• DOI: http://doi.org/10.7461/jcen.2012.14.2.99

Abstract

The blood blister-like aneurysm (BBA) of the internal carotid artery (ICA) is a rare but clinically important cause of subarachnoid hemorrhage (SAH), which accounts for 0.5% of incidences of ruptured intracranial aneurysms. BBA is a thin-walled, broad-based aneurysm that lacks an identifiable neck and is one of the most difficult lesions to treat. In this paper, a case is presented of a 57-year-old woman with SAH. Her cerebral angiography demonstrated a small BBA on the dorsal wall of her right ICA. Endovascular treatment that consisted of a stent-within-a-stent was attempted, but the replacement of the second stent failed, and the aneurysm became bigger. Surgery was performed by clipping the BBA with a Sundt slim-line encircling graft clip. The patient completely recovered with no complications. This treatment may be a salvageable option for BBA, especially when endovascular treatment has failed.

Keyword

Blood-blister like aneurysm; Internal carotid artery; Subarachnoid hemorrhage; Encircling graft clip; Endovascular stent

MeSH Terms

Aneurysm
Carotid Artery, Internal
Cerebral Angiography
Endovascular Procedures
Female
Humans
Incidence
Intracranial Aneurysm
Middle Aged
Neck
Stents
Subarachnoid Hemorrhage
Transplants

Figure

• 

  Fig. 1 On brain computed tomography (CT) scan, subarachnoid hemorrhage is detected (A). On CT angiogram, any aneurysm is not seen definitely (B).

• 

  Fig. 2 Conventional 4-vessel cerebral angiography demonstrates a blood blister-like aneurysmal dilatation at the dorsal wall of the distal internal carotid artery on right. The size is 4.4 × 1.16 mm (A). The next day, angiogram reveals thin dorsal wall aneurysm in right distal ICA which has been increased (B). Four days later, the angiogram reveals dorsal wall aneurysm in right distal ICA which has been increased again (C).

• 

  Fig. 3 After surgical treatment, follow-up angiography reveals good placement of the clip and no leakage of hemorrhage. Mild vascular stenosis developed at the junctional area of the encircling clip, however the blood flow is well preserved (A). At six month later from surgery, no migration of the clip is observed on follow-up skull X-rays (B).

Reference

1. Chung JH, Shin YS, Lim YC, Park M. Ideal internal carotid artery trapping technique without bypass in a patient with insufficient collateral flow. J Korean Neurosurg Soc. 2009. 04. 45(4):260–263.

2. Ishikawa T, Nakamura N, Houkin K, Nomura M. Pathological consideration of a "Blister-like" Aneurysm at the superior wall of the internal carotid artery: Case report. Neurosurgery. 1997. 02. 40(2):403–405. discussion 405-6.

3. Islam MS, Manabe H, Hasegawa S, Takemura A, Nagahata M. 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 extracranialintracranial bypass in the chronic stage. Minim Invasive Neurosurg. 2004. 06. 47(3):165–168.

4. Kim BM, Chung EC, Park SI, Choi CS, Won YS. 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. 2007. 12. 107(6):1211–1213.

5. Lee BH, Kim BM, Park MS, Park SI, Chung EC, Suh SH, et al. Reconstructive endovascular treatment of ruptured blood blister-like aneurysms of the internal carotid artery. J Neurosurg. 2009. 03. 110(3):431–436.

6. Meling TR, Sorteberg A, Bakke SJ, Slettebo H, Hernesniemi J, Sorteberg W. Blood blister-like aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: Treatment and outcome. J Neurosurg. 2008. 04. 108(4):662–671.

7. Nakagawa F, Kobayashi S, Takemae T, Sugita K. Aneurysms protruding from the dorsal wall of the internal carotid artery. J Neurosurg. 1986. 09. 65(3):303–308.

8. Ogawa A, Suzuki M, Ogasawara K. Aneurysms at nonbranching sites in the supraclinoid portion of the internal carotid artery: Internal carotid artery trunk aneurysms. Neurosurgery. 2000. 09. 47(3):578–583. discussion 583-6.

9. Park JH, Park IS, Han DH, Kim SH, Oh CW, Kim JE, et al. Endovascular treatment of blood blister-like aneurysms of the internal carotid artery. J Neurosurg. 2007. 05. 106(5):812–819.

10. Sekula RF Jr, Cohen DB, Quigley MR, Jannetta PJ. Primary treatment of a blister-like aneurysm with an encircling clip graft: Technical case report. Neurosurgery. 2006. 07. 59:1 Suppl 1. ONSE168. discussion ONSE168.

11. Silva JC, Faquini IV, Kitamura MA, Azevedo-Filho HR. Internal carotid artery blood blister-like aneurysm. Arq Neuropsiquiatr. 2008. 09. 66(3A):563–565.

12. Sim SY, Shin YS, Cho KG, Kim SY, Kim SH, Ahn YH, et al. Blood blister-like aneurysms at nonbranching sites of the internal carotid artery. J Neurosurg. 2006. 09. 105(3):400–405.

13. Sundt TM Jr. Clip-grafts for aneurysm and small vessel surgery. 4. Relative application to various aneurysms and repair of anterior communicating aneurysms using right-angle clip holder. Technical note. J Neurosurg. 1972. 12. 37(6):753–758.

14. Yanaka K, Meguro K, Nose T. Repair of a tear at the base of a blister-like aneurysm with suturing and an encircling clip: Technical note. Neurosurgery. 2002. 01. 50(1):218–221.