J Korean Neurosurg Soc.  2014 Dec;56(6):496-499. 10.3340/jkns.2014.56.6.496.

Use of the Sundt Clip Graft in a Previously Coiled Internal Carotid Artery Blister-Like Aneurysm

• Cho JI
• Cho JH

• KMID: 2191142
• DOI: http://doi.org/10.3340/jkns.2014.56.6.496

Abstract

Owing to the focal wall defect covered with thin fibrous tissues, an aneurysm arising from the dorsal wall of the internal carotid artery (ICA) is difficult to manage either surgically or endovascularly and is often associated with high morbidity and mortality. Unfortunately, the definitive treatment modality of such highly risky aneurysm has not yet been demonstrated. Upon encountering the complex intracranial pathophysiology of such a highly precarious aneurysm, a neurosurgeon would be faced with a challenge to decide on an optimal approach. This is a case of multiple paraclinoid aneurysms including the ICA dorsal wall aneurysm, presented with spontaneous subarachnoid hemorrhage. With respect to treatment, direct clipping with a Sundt graft clip was performed after multiple endovascular interventions had failed. This surgical approach can be a treatment modality for a blood blister-like aneurysm after failed endovascular intervention(s).

Keyword

Blood blister-like aneurysm; Endovascular intervention; ICA dorsal wall aneurysm; Multiple paraclinoid aneurysms and Sundt clip graft

MeSH Terms

Aneurysm*
Carotid Artery, Internal*
Mortality
Subarachnoid Hemorrhage
Transplants*

Figure

• 

  Fig. 1 A : Brain CT scan reveals thick and diffuse SAH in the basal cisterns. B : Digital subtraction angiogram demonstrating a blood blister-like aneurysmal dilatation (black arrow) on the dorsal wall of the right distal ICA and a saccular aneurysm (white arrow) on the paraclinoid portion of the right ICA (white arrow). C : Left carotid angiogram reveals a saccular aneurysm (white arrow) on the paraclinoid portion of the left ICA. SAH : subarachnoid hemorrhage, ICA : internal carotid artery.

• 

  Fig. 2 Digital subtraction angiogram after the first coil embolization. An-teroposterior oblique view (A) and lateral view (B) show aneurysms on both ICAs are almost completely obliterated. ICA : internal carotid artery.

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  Fig. 3 A : Follow-up angiography on the 19th day shows further enlargement of the right ICA dorsal wall aneurysm (black arrow). B : Angiography after second embolization demonstrates a delayed filling of the right ICA dorsal wall aneurysm (white arrow) and some thrombus formation (black arrow) distal to the origin site of the right anterior choroidal artery. C : Follow-up cerebral angiogram on the seventh day after second embolization demonstrates recanalization (black arrow) of the right ICA dorsal wall aneurysm. ICA : internal carotid artery.

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  Fig. 4 The aneurysm on the dorsal wall of the ICA is seen in the operative view. Note the endovascular stent struts and coil materials previously inserted into the ICA and the aneurysmal sac, respectively. ICA : internal carotid artery.

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  Fig. 5 Five months later after clipping, angiography demonstrates total obliteration of the right ICA dorsal aneurysm with a patency of the arterial lumen to its normal configuration. ICA : internal carotid artery.

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