Blood Blister-like Aneurysms Research Articles

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

✓Ruptured blood blister–like aneurysms (BBAs) of the internal carotid artery (ICA) are potentially dangerous lesions because of the high risk of intraoperative bleeding associated with their wide fragile neck. The authors discuss cases in which BBAs were treated endovascularly during the chronic stage and report a case in which a ruptured BBA of the ICA was successfully treated in the acute phase with stent-assisted coil embolization and a subsequent stent-within-a-stent procedure.

Endovascular treatment of blood blister–like aneurysms of the internal carotid artery

Because of its thin wall, an aneurysm arising from the posterior wall of the internal carotid artery (ICA), the so-called blood blister-like aneurysm (BBA), is difficult to manage surgically and is often associated with high morbidity and mortality rates. The authors treated these aneurysms endovascularly. In this paper, they present angiographic and clinical results obtained in patients with ICA BBAs treated endovascularly. In seven patients with ICA BBAs who presented with subarachnoid hemorrhage, a total number of 12 endovascular treatments were performed, including seven endosaccular coil embolizations (four conventional, two stent-assisted and one balloon-assisted procedure) in four patients and five endovascular ICA trapping procedures in five patients. Repeated endovascular treatments were undertaken in four patients. In two patients, the endovascular treatment was performed after failure of surgical treatment (one case of rebleeding after clip placement and one aneurysmal regrowth after wrapping). A balloon occlusion test (BOT) was performed in all patients prior to ICA trapping. All four patients treated by endosaccular coil embolization showed aneurysmal regrowth. Neither stents nor balloons helpfully prevented aneurysmal regrowth. Of these four patients, two experienced rebleeding. These two patients remained vegetative at the last follow-up examination. After the BOT, ICA trapping was performed with coils and balloons without complication in five patients; excellent outcomes were achieved in all cases but one in which the patient had been in poor neurological condition due to rebleeding after surgical clip therapy. All ICA BBAs that were treated by endosaccular coil embolization exhibited regrowth of the aneurysm. Some of the lesions rebled. The majority of patients who underwent ICA trapping experienced excellent outcomes. Based on the authors' experiences, they suggest that ICA trapping including the lesion segment should be considered as a first option for definitive treatment if a BOT reveals satisfactory results. Regarding trapping methods, endovascular treatment may be preferred because of its convenience and safety.

Aneurysm at Nonbranching Sites of the Internal Carotid Artery: Blood Blister-like Aneurysm. Report of 4 cases

I encountered 4 cases of blood blister-like aneurysm (3 ruptured and 1 unruptured) during the past 7 years. The unruptured one was accompanied by a ruptured internal carotid-ophthalmic aneurysm. These aneurysms constitute 3.4% of the total of 117 aneurysms managed by open or endovascular surgery during the same period. In these 4 cases, the lesion arose at the nonbranching site on internal carotid artery. The 4 aneurysms were operated upon via a transsylvian approach. A combination of both wrapping and clipping was done in 3 cases, and for the remaining 1 (ruptured) clipping only. The aneurysm managed by clipping only suffered postoperative massive bleeding because of an inappropriate obliteration of the proximal aneurysmal neck. The other 2 ruptured aneurysms that underwent both wrapping and clipping did not suffer any bleeding postoperatively, and 1 patient with an unruptured aneurysm has been in good condition. I detail the course of these 4 cases and problems concerning management for blood blister-like aneurysm.

Blood blister–like aneurysms at nonbranching sites of the internal carotid artery

The clinical features of blood blister-like aneurysms (BBAs) that arise at nonbranching sites of the internal carotid artery (ICA) differ from those of saccular aneurysms. In this study, the authors attempt to describe optimal treatments for BBAs, which have yet to be clearly established. Ten of 483 patients with aneurysmal subarachnoid hemorrhage who had been seen at the authors' institution between March 2001 and June 2005 had intraoperatively confirmed BBAs at nonbranching sites of the ICA. All ten patients were women between the ages of 37 and 64 years (mean age 49.3 years); five had a history of hypertension. The BBAs were localized to the right side of the ICA in seven cases. All patients were successfully treated; clipping was undertaken in six, clipping combined with wrapping in three, and trapping in one. These methods were used in conjunction with various other surgical techniques such as brain relaxation by draining cerebrospinal fluid, anterior clinoidectomy, exposing the cervical ICA, gentle subpial dissection (for aneurysms that adhered to the frontal lobe), complete trapping of the ICA before clipping, and protecting the brain. Clip slippage occurred at the end of dural closing in two cases; the aneurysm was completely obliterated using multiple clips combined with ICA stenosis in one of these cases and ICA trapping with good collateral flow in the other. An excellent clinical outcome was achieved in eight patients, whereas two patients were disabled from massive vasospasm. The authors retrospectively reviewed radiological and surgical data in all cases to determine which treatment methods produced a favorable outcome. Blood blister-like aneurysms located at nonbranching sites of the ICA are difficult to treat. Preoperative awareness and careful consideration of these lesions during surgery can prevent poor clinical outcomes.

ダクロンテープによる微小脳動脈りゅうの治療

Coagulation, coating and wrapping have been adapted as treatments for small cerebral aneurysms among unclippable aneurysm cases, and each brain surgeon decides which method to choose. A strategic method of surgical treatment is required, especially in cases of blood blister-like aneurysms found at the internal carotid artery. Although the methods of wrapping clipping and trapping plus bypass are reported, these are not standard treatments. We have adapted the wrapping-clipping method using Dacron® tape to reinforce after coating and coagulation for cerebral small aneurysms 2-3 mm in diameter. In this method, the cerebral aneurysms as well as the parent artery are wrapped and then clipped at both ends with Dacron® tape. We report 5 cases using this procedure: 4 SAH cases and 1 unruptured aneurysm. Three cases were considered as blood blister-like aneurysms. We used Dacron® tape to reinforce after clipping in the SAH cases and after coating in the unruptured case. The results from the 4 cases in follow-ups averaging 4 years were good. Dacron® tape is excellent operatively; it is reliable as reinforcement material for blood vessels and is useful for unclippable cerebral small aneurysms. In addition, it is also available for blood blister-like aneurysms because we can expect obliteration to maintain good antegrade blood flow. It is necessary to decide the strategic method of surgical treatment preoperatively.

Aneurysms at nonbranching sites in the surpaclinoid portion of the internal carotid artery: internal carotid artery trunk aneurysms.

Aneurysms at nonbranching sites in the supraclinoid internal carotid artery (ICA), known as blood blister-like aneurysms or ICA anterior or dorsal wall aneurysms, are not well understood. To clarify this clinical entity, 7408 patients with subarachnoid hemorrhage who were treated during a 5-year period were analyzed. Forty-eight patients had aneurysms that were intraoperatively confirmed to be located at a nonbranching site in the supraclinoid portion of the ICA. Neuroradiological and clinicopathological features and outcomes were studied. The aneurysms were divided into the "blister type," with a blood blister-like configuration and fragile walls, and the "saccular type," with a saccular configuration and a relatively firm neck, like ordinary berry aneurysms. The most frequent origin was the anteromedial wall for both types. ICA dissection was associated only with the blister type, and hypertension was more frequent with the blister type (P = 0.0978). The preoperative conditions of the patients were the same, but the outcomes for patients with blister-type aneurysms were worse, because of frequent intra- and postoperative aneurysmal bleeding. Saccular-type aneurysms were safely clipped. Treatment of blister-type aneurysms by clipping on wrapping material achieved good results, but ICA trapping (P = 0.0952), clipping (P = 0.0146), and wrapping (P = 0.0110) were associated with much worse results. Blister-type and saccular-type aneurysms have different shapes and wall characteristics. The saccular type can be treated by clipping, whereas the blister type requires clipping on wrapping material. ICA trunk aneurysms may be a better designation to express the diversity of these aneurysms, rather than ICA blood blister-like or anterior or dorsal wall aneurysms.

内頸動脈血豆状動脈瘤に対する頸部内頸動脈塞栓術

A small hemispherical bulging from the anterior wall of the internal carotid artery (ICA), which we call a blood blister-like aneurysm (BBA), is a treacherous lesion. Treatment of this lesion requires special tactics. We report the course of patients with this lesion treated by endovascular occlusion of the cervical ICA with or without bypass surgery.We describe 3 patients with BBAs who presented with subarachnoid hemorrhage (SAH). In these patients, the initial angiogram soon after SAH showed only a small bulging from the anterior wall of the ICA. This bulge progressed to a saccular appearance within a few weeks. Two patients were treated conservatively, and underwent endovascular occlusion of the cervical ICA in the chronic stage, 1 with and the other without STA-MCA anastomosis. One patient underwent direct surgery on the aneurysm in the acute stage; clipping after wrapping with a strip of gauze was performed. Repeated angiogram showed growth of the aneurysm. Endovascular occlusion of the cervical ICA was subsequently performed. All 3 patients did well and returned to their previous life style.Our experience with these lesions, as well as a review of the literature, suggests that direct clipping often causes laceration of the lesion, and wrapping or clipping after wrapping may fail to prevent growth of the aneurysm. Endovascular occlusion of the cervical ICA with or without bypass surgery, which is less risky than direct surgery, is still useful for this kind of lesion.

Blood blisterlike aneurysms of the internal carotid artery.

An aneurysm arising from the anterior wall of the internal carotid artery (ICA) is a poorly understood entity. A small hemispherical bulge from the anterior wall of the ICA, which is called a "blood blisterlike aneurysm" (BBA), may be confused with a tiny berry aneurysm although the clinical features are distinctly different. This paper summarizes the clinical course of patients with this lesion to clarify the nature of the BBA. Six patients with BBAs who presented with subarachnoid hemorrhage (SAH) are described. In all patients, the initial angiogram obtained soon after SAH showed only a small bulge from the anterior wall of the ICA. In three of the six patients this bulge had progressed to a saccular appearance within a few weeks. The wall of the lesion was so thin and fragile that the aneurysm ruptured at the base during clipping or within a few hours after clipping in two patients. From the authors' experience, as well as a review of the literature, which includes an autopsy study of similar cases, it is inferred that these lesions are focal wall defects covered only with thin fibrous tissue and that they are therefore not true aneurysms. Direct clipping often causes laceration of the lesion, whereas complete wrapping or clipping after wrapping is effective, but may fail to prevent growth of the aneurysm. Endovascular occlusion of the cervical ICA with or without bypass surgery, which is less risky than direct surgery, is another option.

The pros and cons of immunization.

<h3>Introduction</h3> Blood blister-like aneurysms (BBAs) are shallow, wide-necked aneurysms, account for 0.5–2% of ruptured intracranial aneurysms. Treatment options are complex and controversial, particularly regarding the timing of endovascular therapy. We prefer to treat these aneurysms at least a week after ictus, after balancing the risks of bleeding, vasospasm, and anticoagulation. <h3>Aim of study</h3> A tertiary neuroscience centre’s experience treating ruptured BBAs with an emphasis on endovascular treatment. <h3>Methods</h3> Clinical records of all patients with subarachnoid haemorrhage secondary to ruptured BBAs presented to our institution between September 2014 and December 2021 were retrospectively reviewed. Data collected included details of aneurysms and treatment, clinical outcomes and follow-up imaging. <h3>Results</h3> We included 19 patients. 14 patients (74%) were treated with endovascular flow diversion, 3 patients (16%) had endovascular coiling and 2 patients (10%) underwent surgical clipping. The median (IQR) time from admission to flow diverter treatment was 8 (4.5 to 15.25) days, during which no patient rebled. No haemorrhagic or thromboembolic complications occurred intraoperatively. All patients had clinical and MRI follow-up over an average of 18 months (range 6–60 months), with complete aneurysm obliteration noted in 17 patients (88%), and residual but stable aneurysm neck in 2 patients (12%). In clinical follow-up, 94% of patients (N=18) had a modified Rankin score of 2 or less after 180 days. No deaths were associated with the subarachnoid haemorrhage or treatment. <h3>Conclusions</h3> Our endovascular treatment approach for ruptured blister aneurysms is safe and effective, with a low risk of procedural complications and favourable clinical outcomes. <h3>References</h3> Peschillo, S <i>et al</i>. “A Systematic Review and Meta-analysis of Treatment and Outcome of Blister-like Aneurysms.” AJNR. <i>American Journal of Neuroradiology</i> Vol. 37,5 (2016): 856–61. DOI:10.3174/AJNR.A4606. Nasra, Mohamed <i>et al</i>. “Contemporary Treatment of Intracranial Blood Blister Aneurysms – A Systematic Review.” <i>Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association</i> Vol. 30,9 (2021): 105968. DOI: 10.1016/J.Jstrokecerebrovasdis.2021.105968. Linfante, Italo <i>et al</i>. “Flow Diversion with Pipeline Embolic Device as Treatment of Subarachnoid Hemorrhage Secondary to Blister Aneurysms: Dual-Center Experience and Review of the Literature.”<i>Journal of Neurointerventional Surgery</i><i>vol</i>. 9,1 (2017): 29–33. DOI:10.1136/Neurintsurg-2016-012287. <h3></h3> <b>Do you have any conflict of interest to declare?</b>: No