A preliminary study on the therapeutic effect of ruptured blood blister-like aneurysms of the supraclinoid internal carotid artery / 中国脑血管病杂志

Objective To investigate the therapeutic effect of choosing reasonable treatment modality for ruptured blood blister-like aneurysms (B B A) of the supraclinoid internal carotid artery. Methods From September 2016 to September 2018, six patients with ruptured BBA of the supraclinoid internal carotid artery admitted to the Department of Neurosurgery of Sanbo Brain Hospital, Capital Medical University were consecutively and retrospectively recruited. DSA were performed to confirm the aneurysms and head CT showed subarachnoid hemorrhage in all patients. There were 3 cases in Hunt-Hess Crade I, 1 case in Grade H,1 case in Grade DI and 1 case in Grade IV. Endovascular treatments were performed in Hunt-Hess grade I - HI patients by double overlapping stents or covered stent according to the characteristics of cerebral angiography. Simultaneous coil embolization was applied in the acute stage of subarachnoid hemorrhage. Microsurgical suture for aneurysms was performed in Hunt-Hess grade IV patients. All patients were followed up by DSA,MR angiography (M R A) or CT angiography (CTA) 6months after operation. A modified Rankin Scale (mRS) was used for postoperative recovery measurement of neurological function (good outcome, mRS 0 -2; bad outcome, mRS 3 -6; and death, mRS 6). Results Among the 6 patients,5 underwent endovascular treatment and 1 underwent microsurgical treatment. Immediate postoperative angiography showed 3 cases of Raymond grade I , 1 case of Raymond grade II and 1 case of Raymond grade IH. No intraoperative rupture of the aneurysms occurred. After the operation, the limb muscle strength was grade V and there was no neurological dysfunction. Cranioplasty was performed 3 months after the operation. The mean follow-up time was 13.6months (range3 to 27 months). MRS score was 0 in4cases, 1 in 1 case and 2 in 1 case. All patients recovered well without recurrence. The parent artery was mild stenosis(stenosis rate was about 20%) in surgical patients. Conclusions For ruptured blood blister-like aneurysms(B B A) of the supraclinoid internal carotid artery, endovascular treatment is preferred in Hunt-Hess grade I - M patients by double overlapping stents or covered stent according to angiographic features, and simultaneous dense coil embolization can be performed in the acute stage of hemorrhage; Microsurgery may be the first choice in higher Hunt-Hess grade. Choosing appropriate treatment modality could achieve satisfactory therapeutic effect.

Overlapping stent-assisted coiling for blood blister-like aneurysms of the internal carotid artery / 医学研究生学报

Objective The treatment methods for blood blister-like aneurysm remain controversial due to its special patholog-ical structure,the risk of post-operative rebleeding and the high rate of recurrence. The arm of this paper is to access the feasibility and effectiveness of overlapping stent-assisted coiling in the treatment of blood blister-like aneurysms of the internal carotid artery. Methods Form January 2014 to December 2016,we treated 15 patients with blood blister-like aneurysm of the internal carotid artery by stent-assisted coiling in the Department of Neurosurgery,5 with two Enterprise tents,3 with three Enterprise tents,4 with Enter-prise+LVIS tents,and 3 with two LVIS tents. We determined the rate of immediate embolization of aneurysms by Raymond-Roy Occlu-sion Classification(RROC)and analyzed the clinical characteristics,postoperative complications,and follow-up data. Results All the coils and stents were successfully implanted. RROC showed 9 cases of gradeⅠ(60%),4 cases of gradeⅡ(27%),and 2 cases of gradeⅢimmediate occlusion(13%),with the parent arteries unobstructed in all the cases. Thrombosis in the stent was found in 2 cases intraoperatively,slight stent migration in 1 case,and internal carotid artery dissection in the petrous segment in another,but no cer-ebral vasospasm or aneurysm rupture in any case.Delayed cerebral in-farct was observed in 2 cases postoperatively. The patients were fol-lowed up for 2 weeks to 28 months,which showed that 11 of them were cured,2 remained stable and 2 developed further thrombosis,with an MRS score of 0-2 in 12 cases,4 in 1 case,5 in 1 case, and 6 in 1case. Conclusion Overlapping stent-assisted coiling is effective for the treatment of blood blister-like aneurysm by reduc-ing the risks of rebleeding and recurrence.

Overlapping low-profile visualized intraluminal support device for blood blister-like aneurysm of the internal carotid artery / 医学研究生学报

Objective Reports are rarely seen on the treatment of blood blister-like aneurysm(BBA)of the internal carotid artery with the overlapping low-profile visualized intraluminal support device(LVIS)stent. This study was to investigate the effects of overlapping versus non-overlapping LVIS stent-assisted coiling in the treatment of BBA. Methods We retrospectively analyzed the clinical data about 15 cases of BBA of the internal carotid artery treated in our hospital from February 2015 to February 2017,11 by o-verlapping and the other 4 by non-overlapping LVIS stent-assisted coiling. Using Raymond-Roy Occlusion Classification(RROC),we evaluated the effects of treatment immediately and at 1 week after operation. We followed up the patients from April 2015 to October 2017 and analyzed the results of follow-up digital subtraction angiogra-phy(DSA)and modified Rankin Scale scores(mRS)of the patients. Results RROC showed 10 cases of grade Ⅰ and 1 case of grade Ⅲocclusion in the overlapping group and 3 cases of gradeⅠand 1 case of gradeⅡin the non-overlapping group right after operation. In com-parison,there were 11 cases of gradeⅠin the overlapping group and 2 cases of grade Ⅰ and 2 cases of grade Ⅱ in the non-overlapping group at 1 week postoperatively.DSA at the end of the follow-up exhibited 9 cases of gradeⅠand 1 case of gradeⅡin the overlapping group and 1 case of grade Ⅰ,2 cases of grade Ⅱ and 1 case of gradeⅢin the non-overlapping group. Satisfactory prognosis was ob-served in all the 15 cases,with mRS=0 in 9 cases and mRS = 1 in 2 cases in the overlapping group and with mRS=0 in 3 cases in mRS=1 in 1 case in the non-overlapping group. Conclusion Overlapping LVIS stent-assisted coiling is safe and effective for treat-ment of BBA of the internal carotid artery.

A Case of Ruptured Blood Blister-like Aneurysm Treated with Pipeline Embolization Device: Clinical Significance of Fetal-type Posterior Communicating Artery / 신경중재치료의학

Blood-blister like aneurysms (BBAs) are challenging lesions because of their wide fragile neck. Flow-diverting stents (FDSs), such as the Pipeline Embolization Device (PED), have been applied to treat BBAs less amenable to more established techniques of treatment. However, the use of FDSs, including the PED, in acute subarachnoid hemorrhage (SAH) still remains controversial. We report a case of aneurysm regrowth following PED application for a ruptured BBA that overlapped the origin of the dominant posterior communicating artery (PCoA), which was successfully treated after coil trapping of the origin of the fetal-type PCoA. And, we discuss the clinical significance of the fetal-type PCoA communicating with a BBA in terms of PED failure.

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.

Surgical management of blood blister-like aneurysms of the internal carotid artery：a 10-year single cen-ter experience / 中国神经精神疾病杂志

Objective To explore the clinical features, surgical techniques and treatment efficacy of blood blis?ter-like aneurysms (BBA) of the internal carotid artery (ICA). Method We retrospectively reviewed 45 BBAs of the ICA treated surgically at our department between Jan. 2006 and Jan. 2016. The data was analyzed. Results Direct clipping of BBA was performed in 38 patients, clipping over wrapping in 3 patients and trapping of ICA in 4 patients. Intraoperative rupture occurred in 12 patients (27%). Postoperative cerebral infarction developed in 10 cases (22%). Seven patients died (16%). During the follow-up time of 47 months (range, 6~126 months), Good results were achieved in 34 patients (76%) with a modified Rankin Scale (mRS) 0~2 and 4 patients were in mRS 3~5. Follow-up angiography revealed a re?currence of BBA in one patient, which was retreated with endovascular coiling. No rebleeding was found in all fol?lowed-up patients. Conclusions BBAs of the ICA are difficult to treat surgically with high risk and complications. Thoughtful pre-operative evaluation of BBA and application of various surgical strategies during operation can signifi?cantly reduce the surgical risk and achieve good outcomes.

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).

Blood Blister-Like Aneurysm with Rupture Point Close to Origin of Anterior Choroidal Artery

If a ruptured blood blister-like aneurysm (BBA) arises from the lateral or superolateral wall of the internal carotid artery (ICA) at the level of the anterior choroidal artery (AChA), its proximity to the origin of the AChA presents a serious surgical challenge to preserve the patency of the AChA. Two such rare cases are presented, along with successful surgical techniques, including the application of a C-shaped aneurysm clip parallel to the ICA and a microsuture technique to repair the arterial defect. The patency of the AChA and ICA was successfully preserved without recurrence or rebleeding of the BBA during a 1-year follow-up after the operation.

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

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.

Aneurismas cerebrales de crecimiento rápido: análisis de siete casos ilustrativos / Fast-growing brain aneurysms: analysis of seven illustrative cases

Se seleccionó de manera restrospectiva siete casos de aneurismas cerebrales que demostraron crecimiento rápido en estudios de imágenes subsecuentes. Tres estaban localizados en la circulación anterior (un aneurisma “blood blister like”, uno silviano y un “berry” aneurisma comunicante anterior) y tres en la circulación posterior (aneurismas de arteria basilar). Basado en los seis casos descritos y revisión de literatura, el crecimiento de aneurismas no relacionado al flujo sanguíneo se puede dividir en dos grupos. Uno compuesto por aneurismas aparentemente pequeños en relación al tamaño real al momento del diagnóstico angiográfico debido al trombo luminal o vasoespasmo en la arteria de origen. El otro grupo representado por aneurismas, probablemente disecantes en su origen, que crecen debido a cambios en su pared. El curso natural, así como el tratamiento de estos aneurismas implica un alto riesgo de morbilidad y mortalidad.

Ideal Internal Carotid Artery Trapping Technique without Bypass in a Patient with Insufficient Collateral Flow

Internal carotid artery (ICA) trapping can be used for treating intracranial giant aneurysm, blood blister-like aneurysms and ICA rupture during the surgery. We present a novel ICA trapping technique which can be used with insufficient collaterals flow via anterior communicating artery (AcoA) and posterior communicating artery (PcoA). A patient was admitted with severe headache and the cerebral angiography demonstrated a typical blood blister-like aneurysm at the contralateral side of PcoA. For trapping the aneurysm, the first clip was placed at the ICA just proximal to the aneurysm whereas the distal clip was placed obliquely proximal to the origin of the PcoA to preserve blood flow from the PcoA to the distal ICA. The patient was completely recovered with good collaterals filling to the right ICA territories via AcoA and PcoA. This technique may be an effective treatment option for trapping the aneurysm, especially when the PcoA preservation is mandatory.

Evaluation of Surgery for Aneurysms that arise from a Non-Branching Site of the Intracranial Internal Carotid Artery (ICA) / 대한뇌혈관외과학회지

OBJECT: Surgery for aneurysms at non-branching sites of an internal carotid artery (ICA) is considered based on the size, shape, direction and site of the aneurysm. In this study, we analyzed characteristics of aneurysms that have arisen from non-branching sites of an ICA from the viewpoint of surgery. METHODS: From 2003 to 2007, 346 intracranial aneurysms were treated at our institute. 19 (5.5%) aneurysms were non-branching site aneurysms of an ICA. Surgery for these aneurysms was retrospectively analyzed in view of the treatment strategy according to the site, size, and configuration of the aneurysms in videos obtained during surgery. RESULTS: There were 13 cases of a ruptured aneurysm (68.4%) and six cases of an unruptured aneurysm (31.6%). There were ten cases of a saccular type of aneurysm (52.6%) and nine cases of a blood blister-like aneurysm (47.4%). There were seven aneurysms that arose from the dorsal wall of an ICA (36.8%), six aneurysms that arose from the ventral wall (31.6%), four aneurysms that arose from the lateral wall (21.1%) two aneurysms that arose from the medial wall (10.5%). Three patients with unruptured blood blister-like aneurysms underwent simple wrapping and wrapping with the use of clip. Three unruptured saccular aneurysms could be clipped perpendicular to an ICA or at a slant to an ICA. Three out of six (50%) ruptured blood blister-like aneurysms were ruptured during surgery. These aneurysms were clipped with the partial wall of an ICA, resulting in ICA stenosis. We treated 15 (84%) of 19 cases by only clipping, one case (5.2%) was treated by clipping with bypass surgery and three cases (15%) were treated by wrapping. CONCLUSION: Ruptured aneurysms of nonbranching sites of an ICA such as blister-like or dorsal saccular aneurysms have a high risk of rupture and can be difficult to clip. If clipping of the aneurysms is possible, preoperative balloon test occlusion should be performed to avoid ICA stenosis after clipping of the aneurysm neck with the arterial wall. Clipping after bypass or trapping can vary the treatment strategy and improve patient outcome. For small-unruptured aneurysms from nonbranching sties of an ICA, wrapping with the use of clip may be a useful method for treatment regardless of the clipping direction.

Segmental Occlusion of Ruptured Internal Carotid Artery Dorsal Bleb / 신경중재치료의학

Two cases of blood blisterlike aneurysm or dorsal bleb of the internal carotid artery (ICA) underwent segmental occlusion of the aneurysmal segment and trapping of the ICA. With this procedure, the causative lesions were successfully excluded from the circulation and moderate to good clinical outcome could be attained. We describe these cases with review of the literature.

Rebleeding after stenting and coil embolization of an aneurysm in anterior wall of the internal carotid artery / 介入放射学杂志

Objective To report a case of early rebleeding of an arterial wall wide-necked aneurysm of the internal carotid artery with stenting and coil embolization. Methods Balloon-expandable stent was deployed across the aneurismal neck through endovascular approach. Microcatheter was superselectively introduced into the aneurismal sac for coil packing. Results The procedure was technically successful with stent completely covering the neck and 90% occlusion by coil packing of the aneurysm; simultaneously keeping the patency of parent artery and adjacent perforating arteries. The patient recovered well, but died for rerupture and rebleeding of the treated aneurysm on the 16th day after the procedure. Conclusions Endovascular stenting combined with coil embolization is an alternative method for treating anterior wall wide-necked aneurysm of the internal carotid artery, but attention and recognition of the risk of early rebleeding of the treated aneurysms should always be kept on mind therefore short-term follow-up and prompt treatment are critically necessary.