Background Ruptured blister aneurysms of the carotid artery are difficult to safely treat. We present a novel strategy of microsurgical clip wrapping of internal carotid artery blister aneurysms in the setting of acute rupture, followed by delayed placement of a pipeline embolization device for definitive treatment.

Clinical presentation We present two cases of ruptured blister aneurysms of the internal carotid artery treated by wrapping of the diseased segment of the vessel, followed by delayed deployment of a flow diverting stent once the patient was out of the vasospasm window but during the same hospitalization.

Results Clip wrapping followed by flow diversion in a delayed fashion results in anatomic remodeling of the diseased artery without a high morbidity.

Conclusions A combined approach of acute surgical stabilization followed by definitive endovascular reconstruction may reduce hemorrhagic complications while improving long term treatment durability.