These blood-blister aneurysms(BBAs)–domes without necks–are fragile and treacherous. Even if the lesion is “perfectly” clipped, the weakened arterial wall beneath the clip can continue to dilate. So, trapping after a bypass is a reasonable surgical recourse. Alternatively, however, I suggest a Sundt-type circumferential “clip-graft” might effectively manage this type lesion without the need for a concurrent bypass procedure. Abe and colleagues present an overview of blister aneurysms: Abe M, Tabuchi K, Yokoyama H, Uchino A. Blood blisterlike aneurysms of the internal carotid artery. Journal of Neurosurgery. 1998;89(3):419-424.
Ira Denton
I thank you Drs. Spallone, Denton and Skaba for their thoughtful and constructive comments. Regarding Dr. Spallone’s comment on using right-angle fenestrated clip, I’d say that one may notice by looking at angiogram (unfortunately you guys don’t see all projections) that this aneurysm in particular and almost all of blood blister-like aneurysms of the supraclinoid ICA in general involve a segment of the ICA 180 degree, leaving limited normal vessel wall for reconstructing with clips. In this case, the diseased segment was involving the origin of the PCOM and only medial wall was somewhat intact. I don’t think reconstruction of this segment could be possible by any clipping strategy even including Sundt’s clip-gratf which would not close because of origin of the PCOM.
I came to know the fact that these type of aneurysms actually exist when I was doing my fellowship with Prof. Sugita in Nagoya, Japan. As you know Sugita’s group was the first group of neurosurgeons who recognized this entity and called these aneurysms “dorsal wall ICA aneurysms”. Since then, many have been described and they gained reputation of having very fragile walls, lack of aneurysm neck and tendency to avulse with minimal surgical or endovascular manipulation. They have been given different names by different authors. Ogawa et al coined the name “supraclinoid ICA trunk aneurysms” for all aneurysms originating from non-banching supraclinoid sites, including both blister-like and saccular types. Blister-like aneurysms don’t share the same pathologic features as saccular berry aneurysms. However, they show similarities with dissecting aneurysms. Multiple strategies for primary treatment have been attempted including surgical wrapping, clip placement, clip placement after wrapping, endovascular coil embolization with or without stents, or any combination of these and surgical trapping with or without bypass. Primary treatment of blister-like aneurysms surgically and endovascularly is associated with high morbidity and mortality rates and usually doesn’t provide lasting results. In contrast, saccular aneurysms at non-branching sites may be amenable to clip or coil embolization.
I have published my experience on 4 blister-like aneurysms treated with EC-IC bypass and trapping (Baskaya et al. Neursurg Focus vol:24(2): E13, 2008). After these initial 4 cases, I have treated 2 more, one of which is presented in this forum. Based on 6 cases, it seems to me, best and long lasting treatment option in blister-like aneurysms of the supraclinoid ICA in high grade SAH patients appears to be exclusion of the diseased segment of the artery by trapping only or trapping with bypass.
Again, I thank you all and Surgical Neurology International for this opportunity to discuss these challenging aneurysms.
Many thanks for your comments on blister like aneurysms,we came accross a few cases in the past years,standard of treatment in our department is to wrap them with cotton threads hopping to provoque scar tissue formation and strenght the vessel wall,on one ocassion however the patient rebled while still in the hospital taking her back to theater, on reopening and exposing the carótid, decided to set the bipolar coagulator on 15,and while the assistant dropped continuosly saline, cauterization of the carótid wall was achieved succesfully causing the blister to disapear completely, at six year follow up the patient is healthy and a angiography done recently shows no abnormalty.
I must say that we do not have acces to endovascular procedures.
Many thanks.For the opportunity
I think all depends on what type of blister aneurysm you are dealing with. I believe these aneurysms range from some simple blisters to large pseudoaneurysms. I do bipolar remodelling technique in saccular aneurysms but would be hesitant to try it in blister aneurysms. Since before we explore we don’t know what we are going to encounter in these cases we’d better prepared by doing balloon test occlusion or other means. Thanks for sharing your experience with us.
This type of aneurysm is a big challenge. We must always think in diseccting aneurysm, and the treatment by endovascular stent reconstruction is a great alternative. Today there are a lot of brain stents (open cell, close cell and a new generation called diverter flow stents). Stents with close cell are the election and as soon as the stent was implanted the flow inside the aneurym change and thrombosed. Congratulation for your great job
It seems a medium sized PcomA in the opposite site of the blood blister-like aneurysm. Is it reasonable to sacrifice the PcomA while trapping of diseased ICA ?
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Aldo Spallone
Posted March 16, 2011, 8:01 am
Couldn’t you try to clip the aneurysms itself using a right-angle fenestrated clip? Congratulation for the beautiful procedure anyway!
Aldo Spallone
Ira Denton
Posted March 16, 2011, 7:33 pm
These blood-blister aneurysms(BBAs)–domes without necks–are fragile and treacherous. Even if the lesion is “perfectly” clipped, the weakened arterial wall beneath the clip can continue to dilate. So, trapping after a bypass is a reasonable surgical recourse. Alternatively, however, I suggest a Sundt-type circumferential “clip-graft” might effectively manage this type lesion without the need for a concurrent bypass procedure. Abe and colleagues present an overview of blister aneurysms: Abe M, Tabuchi K, Yokoyama H, Uchino A. Blood blisterlike aneurysms of the internal carotid artery. Journal of Neurosurgery. 1998;89(3):419-424.
Ira Denton
Tomas Skaba
Posted March 24, 2011, 10:01 pm
Congratulation for the beautiful procedure anyway
Mustafa K. Baskaya
Posted April 9, 2011, 8:10 pm
I thank you Drs. Spallone, Denton and Skaba for their thoughtful and constructive comments. Regarding Dr. Spallone’s comment on using right-angle fenestrated clip, I’d say that one may notice by looking at angiogram (unfortunately you guys don’t see all projections) that this aneurysm in particular and almost all of blood blister-like aneurysms of the supraclinoid ICA in general involve a segment of the ICA 180 degree, leaving limited normal vessel wall for reconstructing with clips. In this case, the diseased segment was involving the origin of the PCOM and only medial wall was somewhat intact. I don’t think reconstruction of this segment could be possible by any clipping strategy even including Sundt’s clip-gratf which would not close because of origin of the PCOM.
I came to know the fact that these type of aneurysms actually exist when I was doing my fellowship with Prof. Sugita in Nagoya, Japan. As you know Sugita’s group was the first group of neurosurgeons who recognized this entity and called these aneurysms “dorsal wall ICA aneurysms”. Since then, many have been described and they gained reputation of having very fragile walls, lack of aneurysm neck and tendency to avulse with minimal surgical or endovascular manipulation. They have been given different names by different authors. Ogawa et al coined the name “supraclinoid ICA trunk aneurysms” for all aneurysms originating from non-banching supraclinoid sites, including both blister-like and saccular types. Blister-like aneurysms don’t share the same pathologic features as saccular berry aneurysms. However, they show similarities with dissecting aneurysms. Multiple strategies for primary treatment have been attempted including surgical wrapping, clip placement, clip placement after wrapping, endovascular coil embolization with or without stents, or any combination of these and surgical trapping with or without bypass. Primary treatment of blister-like aneurysms surgically and endovascularly is associated with high morbidity and mortality rates and usually doesn’t provide lasting results. In contrast, saccular aneurysms at non-branching sites may be amenable to clip or coil embolization.
I have published my experience on 4 blister-like aneurysms treated with EC-IC bypass and trapping (Baskaya et al. Neursurg Focus vol:24(2): E13, 2008). After these initial 4 cases, I have treated 2 more, one of which is presented in this forum. Based on 6 cases, it seems to me, best and long lasting treatment option in blister-like aneurysms of the supraclinoid ICA in high grade SAH patients appears to be exclusion of the diseased segment of the artery by trapping only or trapping with bypass.
Again, I thank you all and Surgical Neurology International for this opportunity to discuss these challenging aneurysms.
Ramon Migliorisi
Posted April 21, 2011, 9:20 am
Many thanks for your comments on blister like aneurysms,we came accross a few cases in the past years,standard of treatment in our department is to wrap them with cotton threads hopping to provoque scar tissue formation and strenght the vessel wall,on one ocassion however the patient rebled while still in the hospital taking her back to theater, on reopening and exposing the carótid, decided to set the bipolar coagulator on 15,and while the assistant dropped continuosly saline, cauterization of the carótid wall was achieved succesfully causing the blister to disapear completely, at six year follow up the patient is healthy and a angiography done recently shows no abnormalty.
I must say that we do not have acces to endovascular procedures.
Many thanks.For the opportunity
Mustafa K. Baskaya
Posted April 24, 2011, 2:56 pm
Dr. Migliorisi,
I think all depends on what type of blister aneurysm you are dealing with. I believe these aneurysms range from some simple blisters to large pseudoaneurysms. I do bipolar remodelling technique in saccular aneurysms but would be hesitant to try it in blister aneurysms. Since before we explore we don’t know what we are going to encounter in these cases we’d better prepared by doing balloon test occlusion or other means. Thanks for sharing your experience with us.
Francisco Villasante
Posted May 4, 2011, 11:30 pm
This type of aneurysm is a big challenge. We must always think in diseccting aneurysm, and the treatment by endovascular stent reconstruction is a great alternative. Today there are a lot of brain stents (open cell, close cell and a new generation called diverter flow stents). Stents with close cell are the election and as soon as the stent was implanted the flow inside the aneurym change and thrombosed. Congratulation for your great job
Hung-Lin Lin
Posted December 11, 2023, 1:08 am
It seems a medium sized PcomA in the opposite site of the blood blister-like aneurysm. Is it reasonable to sacrifice the PcomA while trapping of diseased ICA ?