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

Abstract

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®, 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.

Supraclinoid internal carotid artery blister-like aneurysms: hypothesized pathogenesis and microsurgical clipping outcomes

“…In contrast, eight other cases had eccentric sclerosis on the ICA walls, which were medially or laterally adjacent to the aneurysms, and three young patients had no signs of atherosclerosis. We searched ten cases in the previous literatures harboring BLAs on the supraclinoid ICA that originated thoroughly from the sclerotic plaque, according to the illustrated figures or the authors’ literal narrations [ 3 , 5 , 7 – 13 ]. Therefore, we suggest, based on the ubiety between both lesions, that BLAs should be classified into 3 groups.…”

Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results

“…Therefore, the idea of combining clipping and wrapping arises. An array of techniques to perform COW have been proposed;9, 10, 25, 27, 28, 29, 30, 33, 44, 60, 61, 62, 63, 64 however, it is difficult to evaluate the efficacy and outcomes of these methods as a single entity. For example, some groups used clipping to fixate only wrapping material covering the BBA without including the artery wall 30, 32.…”

“…For example, some groups used clipping to fixate only wrapping material covering the BBA without including the artery wall 30, 32. It is not ideal to use an elastic material such as fascia, cotton, or polyglycolic acid sheet (Neoveil; Gunze, Osaka, Japan) to cover a fragile BBA, which is being constantly stressed by a high pressure of ICA, without a strong physical pressure 9, 30, 63. It might be better, strength-wise, if a less elastic material such as an expanded polytetrafluoroethylene sheet (Gore-Tex; W.L.…”

“…However, the ICA is not straight, and as its diameter varies as it ascends, it is difficult to adhere a nonelastic material tightly to the lesion. Even a slight gap between the BBA's wall and the wrapping material may allow the BBA to regrow 63 . Furthermore, it is technically very difficult to wrap a rigid material around a lesion that involves a complex shape where the origin of the PcomA or AchA arises.…”

The Blood Blister Like-aneurysm: Usefulness of Sundt Clip

“… 12) In morphological aspect, the dorsal wall aneurysm can be divided into blood blister-like aneurysm (BBA) and saccular type aneurysm. 4) 13) Because of its small-sized, broad-base thin neck, fragility, tendency to intraoperative bleeding, 4) 6) 9) 12) 13) 18) sometimes that makes it difficult for neurosurgeons.…”