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.

Combination Treatment for Rapid Growth of a Saccular Aneurysm on the Internal Carotid Artery Dorsal Wall: Case Report

Aneurysms arising from non-branching sites of the supraclinoid internal carotid artery (ICA) are considered rare, accounting for only 0.9-6.5% of all ICA aneurysms. They are thin-walled, broad-based, can easily rupture during surgery, and are referred to as dorsal, superior, anterior, or ventral wall ICA aneurysms, as well as blister-like aneurysms. Various treatment modalities are available for blister-like aneurysms, but with varying success. Here, we report on two cases of saccular shaped dorsal wall aneurysms. Both patients were transferred to the emergency department with subarachnoid hemorrhage because of an aneurysmal rupture. Computed tomography angiography and transfemoral cerebral angiography (TFCA) showed a dorsal wall aneurysm in the distal ICA. We performed clipping on the wrapping material (Lyodura(R), temporal fascia). Follow-up TFCA showed rapid configuration changes of the right distal ICA. Coil embolization was also performed as a booster treatment to prevent aneurysm regrowth. Both patients were discharged without neurologic deficit. No evidence of aneurysm regrowth was observed on follow-up TFCA at two years. Dorsal wall ICA aneurysms can change in size over a short period; therefore, follow-up angiography should be performed within the short-term. In cases of regrowth, coil embolization should be considered as a booster treatment.

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

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).

Direct Repair of a Dorsal Wall Aneurysm on Supraclinoid Internal Carotid Artery

Aneurysms arising at locations other than arterial division are rare and the incidence of intraoperative bleeding is far higher in such aneurysms than in usual aneurysms. The authors report a case of intraoperative rupture and laceration on internal carotid artery(ICA) wall during dissecting a dorsal wall aneurysm on supraclinoid ICA and successful repair of the laceration on the parent ICA with microsuture and a Sundt clip-graft.

Surgical Experience of Unbranched Dorsal Wall of the Internal Carotid Artery Aneurysms

Most intracranial saccular aneurysms arise from the distal angle between a parent vessel and an arterial branch. We present three cases of saccular aneurysms arising from the unbranched-site of the dorsal wall of the intracranial internal carotid artery(ICA) total of 162 ICA aneurysms(1.9%). All three cases presented with sudden onset of headache and mental deterioration. Computerized tomography(CT) scans revealed typical pattern of aneurysmal subarachnoid hemorrhage. With transfemoral cerebral angiography(TFCA) dorsal wall aneurysms were easily detected except one case, which we missed small bulging at unusual site on initial TFCA. Second TFCA of this particular case a definite aneurysmal dilatation at dorsal wall of intracranial ICA. The operative findings disclosed darkish red entirely thin-walled aneurysms pointing to the sylvian cistern, attached to either temporal lobe or optic nerve. In two cases aneurysms were ruptured during neck dissection. The authors emphasize the pathogenesis and surgical points of this particular type of aneurysm with review of patient literatures.

Internal Carotid Artery Aneurysms Arising Remote from Arterial Divisions: Dorsal and Medical ICAA

Aneurysms arising remote from arterial divisions are rare. From January 1981 to December 1993, We operated on 271 internal carotid artery aneurysms(ICAA). Among them, we found nine of such unusual aneurysms protruding from the dorsal(six cases) or medical wall(three cases) of the internal carotid artery. Angiographically, they were often misdiagnosed as the posterior communicating artery aneurysms or carotid artery bifurcation aneurysm due to small size and flat shape with broad neck. On operation, all three medical wall aneurysms showed severe atherosclerosis. and moderate to minimal atherosclerosis was found in four dorsal wall aneurysms. In four cases, we experienced intraoperative premature rupture of the aneurysm, one during retraction of the frontal lobe due to adhesion of the aneurysmal dome to the base of frontal lobe, two during aneurysmal neck dissection and the other one during clip application. These aneurysms were difficult to operate on because of their fragility(thin or atherosclerotic wall) and relatively board aneurysmal neck. In conclusion, these aneurysms presented with difficulties in preoperative diagnosis by angiography due to small size and flat shape. In operation, special care should be taken to avoid premature rupture of the aneurysm due to thin or atherosclerotic fragile wall.