Elsevier

Surgical Neurology

Volume 65, Issue 6, June 2006, Pages 628-630
Surgical Neurology

Aneurysm
Aneurysmal embolization of a blisterlike aneurysm of the internal carotid artery: a case report and review of the literature

https://doi.org/10.1016/j.surneu.2005.09.030Get rights and content

Abstract

Background

Little is known regarding the optimal management of a ruptured blisterlike aneurysm of the ICA. Because of the high risk for intraoperative bleeding, direct surgical treatments of these fragile lesions have generally been associated with a poor outcome. We herein report a very rare case of a ruptured blisterlike aneurysm that was successfully treated with coil embolization in the late period.

Case Description

The patient was 21 years old when he had a Hunt and Hess grade IV subarachnoid hemorrhage. At the time of the hemorrhage, 3D-CTA demonstrated a minimal aneurysmal enlargement located in the left C2 portion of the ICA. Because of his poor neurological condition and the risk for a premature rupture during early surgery, delayed surgery was thus scheduled. Cerebral angiography, 13 days later, revealed the shape and size of the aneurysm to have changed in form from a blisterlike aneurysm to a saccular-type one. Initially, we planned to treat the aneurysm by trapping with bypass surgery on the 15th day. However, we instead performed coil embolization on the 19th day because a thick thrombus was found to cover the aneurysm at the time of surgery on the 15th day.

Conclusion

This is the first report of a ruptured blisterlike aneurysm that was successfully treated with coil embolization in the late period of a subarachnoid hemorrhage after operative confirmation of thrombus formation around the aneurysm. Our findings suggest that coil embolization in the late period appears to be an effective option in the management of selective cases of ruptured blisterlike aneurysms.

Introduction

Blisterlike aneurysms of the supraclinoid ICA have recently been recognized as having unique pathological and clinical features. These are rare types of aneurysms, which have been found to comprise 0.9% to 6.5% of all ICA aneurysms [4]. It is important to recognize this type of aneurysm because of their very fragile nature, high rate of intraoperative and postoperative bleeding, and tendency to progress in size over a short period. Various surgical and endovascular approaches have been described for the treatment of blisterlike aneurysms. However, the optimal treatment strategy remains to be elucidated. To our knowledge, there were few cases of blisterlike aneurysms treated by a GDC. We herein report the case of a blisterlike aneurysm of the ICA treated with GDC embolization on the 19th day of subarachnoid hemorrhage. In addition, the clinical features as well as the therapeutic difficulties in other such cases are also reviewed.

Section snippets

Case report

A 21-year-old man experienced a sudden onset of a severe headache while he was working. Because of a gradual deterioration of consciousness, he was brought to the emergency department of our hospital. The patient presented with unconsciousness but no other neurological deficits. His condition was graded Hunt and Hess grade IV. His medical history was unremarkable other than mental deterioration and no particular medication history. His family history was negative for cerebrovascular disease. CT

Discussion

Generally, blisterlike aneurysms are rare, representing only 0.9% to 6.5% of all ICA aneurysms [4]. In addition, such aneurysms tend to have a worse prognosis than other aneurysms because they are fragile and often rupture prematurely during surgical exposure, thus resulting in a higher morbidity. In previous reports, various surgical procedures have been described for the treatment of such aneurysms [1], [4]. The optimal treatment method is the application of a clip, with the clip blades

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    In 2004, Tanoue et al. [10] reported a case of a ruptured BA of the supraclinoid ICA that was successfully treated with coil embolization 40 days after admission. In another report, in 2006, Ezaki et al. [9] reported a case of a ruptured BA, for which DSA images obtained 3 days after hemorrhage revealed a morphological shift in the aneurysm from a BA to a saccular type. After 19 days, the patient underwent coil embolization without complications.

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    Many attempts have been made to improve endovascular techniques for the treatment of blister aneurysms. In a study by Ezaki et al. it was reported that despite successful placement of coils could be performed in one case of a blister aneurysm, follow-up evaluation indicated progressive growth and transformation into a saccular aneurysm [16]. Park et al. reported about seven patients with blister aneurysms who were treated with coil embolization.

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  • Treatment of ruptured internal carotid artery trunk aneurysms: Feasibility of endovascular trapping or proximal obliteration of the ICA

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