Elsevier

Surgical Neurology

Volume 66, Issue 4, October 2006, Pages 424-428
Surgical Neurology

Aneurysm—Technique
Arterial suturing followed by clip reinforcement with circumferential wrapping for blister-like aneurysms of the internal carotid artery

https://doi.org/10.1016/j.surneu.2006.01.024Get rights and content

Abstract

Objective

Blister-like aneurysms of the internal carotid artery (ICA) are very fragile, thin-walled aneurysms. These lesions are susceptible to premature rupture intraoperatively. We describe two cases of successful arterial suturing of these blister-like aneurysms of the ICA, followed by a clip reinforcement technique and circumferential wrapping with a silastic sheet.

Methods

Two young men presented with a diffuse and dense subarachnoid hemorrhage (SAH) in the basal cistern. The initial angiogram obtained soon after the SAH showed a broad-based, small bulging appearance of the dorsal wall of the ICA. Intraoperatively, a very thin-walled aneurysm was identified on the C2 and C1 segment of the ICA. The aneurysms ruptured abruptly during surgical manipulation. After application of temporary clips, an aneurysmal tear of the ICA was repaired with 8-0 nylon. To prevent the regrowth of the aneurysm, clip reinforcement, by circumferential wrapping with a transparent silicone sheet, was added.

Results

The postoperative clinical course was uneventful, although one patient showed transient right hemiparesis due to cerebral vasospasm. Angiographic studies performed postoperatively showed complete obliteration of the aneurysm as well as a patent ICA lumen in one case and total occlusion of the ICA in the other case. Both patients were discharged with no neurological deficits.

Conclusion

This technique can be a useful treatment option for these fragile aneurysms in cases where other options, such as direct clips or encircling clips, may be impossible.

Introduction

Aneurysms arising from the dorsal wall of the ICA, known as blister-like aneurysms, have been reported to have extremely thin, fragile walls with a marked tendency to rupture intraoperatively [1], [2], [5], [7], [10], [11], [14], [16]. These lesions rupture easily with surgical manipulation, resulting in an arterial wall defect in the ICA. In such situations [1], [5], [7], it is very difficult to reconstruct the ICA while preserving patency of the parent artery. Recently, we had an intraoperative arterial tear at the base of a blister-like aneurysm. We report two cases of a useful technique where direct suture of the arterial tear on the blister-like aneurysm, followed by a clip reinforcement technique and circumferential wrapping with silastic sheet, was successfully used.

Section snippets

History and examination

This 30-year-old man had a sudden onset of headache and vomiting. He was initially transported to a local hospital before he was referred to our hospital for further management of SAH. On admission, his neurological symptoms were unremarkable except for drowsiness. His condition was graded as Hunt and Hess grade III. Computerized tomography showed a dense and diffuse SAH at the basal cistern and sylvian fissure that was slightly more prominent on the left side. Cerebral angiographic studies

Discussion

Aneurysms arising from the dorsal wall of the ICA are quite rare; they are reported to comprise 0.3% to 1% of all intracranial aneurysms or 0.9% to 6.5% of aneurysm of the ICA [15]. These aneurysms have been classified into two groups according to shape: one is a small hemispherical bulge that is called “blood blister–like aneurysm” (BBA) [1] and the other is a saccular type aneurysm. A BBA is also called a semifusiform aneurysm [7], [11] or a blister-like aneurysm [5]. Blister-like aneurysms

Conclusion

We have successfully used a technique of direct suture of the blister-like aneurysm in the ICA followed by clip reinforcement and circumferential wrapping. This method can be a useful treatment option for these fragile aneurysms in cases where other options, such as direct clips and encircling clips (which are not generally available in modern aneurysm clip trays), may be impossible. Aneurysmal rupture at the neck of the vessel does occur occasionally and can be treated using the described

References (17)

  • M. Abe et al.

    Blood blisterlike aneurysms of the internal carotid artery

    J Neurosurg

    (1998)
  • G.P. Cantore et al.

    Treatment of aneurysms unsuitable for clipping or endovascular therapy

    J Neurosurg Sci

    (1998)
  • T. Haisa et al.

    Foreign-body granuloma as a complication of wrapping and coating an intracranial aneurysm. Case report

    J Neurosurg

    (1990)
  • M.D. Heifetz

    A new intracranial aneurysm clip

    J Neurosurg

    (1969)
  • T. Ishikawa et al.

    Pathological consideration of a “blister-like” aneurysm at the superior wall of the internal carotid artery: case report

    Neurosurgery

    (1997)
  • N. Miyazawa et al.

    Treatment of intradural paraclinoidal aneurysms

    Neurol Med Chir (Tokyo)

    (1999)
  • F. Nakagawa et al.

    Aneurysms protruding from the dorsal wall of the internal carotid artery

    J Neurosurg

    (1986)
  • A. Ogawa et al.

    Aneurysms at nonbranching sites in the surpaclinoid portion of the internal carotid artery: internal carotid artery trunk aneurysms

    Neurosurgery

    (2000)
There are more references available in the full text version of this article.

Cited by (52)

  • Microsuturing Technique for the Treatment of Blood Blister Aneurysms: A Series of 7 Cases

    2020, World Neurosurgery
    Citation Excerpt :

    To date, few reports have explored the use of MST for the treatment of BBAs (Table 2).37-39 Some studies have reported on direct suturing, although this approach is usually recommended as a remedy for intraoperative rupture.28,33,40,41 First, this method is required only for the short period during which temporary occlusion of the parent artery is applied for repair, and this helps to avoid ischemic complications.

  • Outcome of a Blood Blister-Like Aneurysm Treated by Clip-Reinforced Wrapping Technique Using Y-Shaped Temporalis Fascia for Perforator Protection

    2019, World Neurosurgery
    Citation Excerpt :

    According to the literature, many wrapping materials, such as gauze,22 Gore-Tex,10 polytetrafluoroethylene,8 cellulose fabric,9 Bemsheets,11 and silicon sheets,12 have been used, but all of these materials are artificial. Their lack of biological activity may result in a foreign-body granuloma to stenose the parent artery, leading to neurologic deficits.12,22-24 For this reason, we used autologous temporalis fascia as a wrapping material, which exhibits good biological activity.

View all citing articles on Scopus
View full text