Current status of the treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery: A review

Abstract

Currently, the treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) is challenging and utilizes many therapeutic methods, including direct clipping and suturing, clipping after wrapping, clipping after suturing, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass. In these therapeutic approaches, the optimal treatment method for BBAs has not yet been defined based on the current understanding of BBAs of the supraclinoid ICA. Therefore, in this study, we aimed to review the literature from PubMed to discuss and analyze the pros and cons of the above approaches while adding our own viewpoints to the discussion. Among the surgical methods, direct clipping was the easiest method if the compensation of the collateral circulation of the intracranial distal ICA was sufficient or direct clipping did not induce stenosis in the parent artery. In addition, the clipping after wrapping technique should be chosen as the optimal surgical modality to prevent rebleeding from these lesions. Among the endovascular methods, multiple overlapping stents (≥3) with coils may be a feasible alternative for the treatment of ruptured BBAs. In addition, flow-diverting stents appear to have a higher rate of complete occlusion and a lower rate of retreatment and are a promising treatment method. Finally, when all treatments failed or the compensation of the collateral circulation of the intracranial distal ICA was insufficient, the extracranial-intracranial (EC-IC) arterial bypass associated with surgical or endovascular trapping, a complex and highly dangerous method, was used as the treatment of last resort.

A Patient with a Ruptured Blood Blister-like Aneurysm of the Internal Carotid Artery in Whom Two LVIS Stents Were Inserted

“…Treatment of ruptured BBAs of the ICA is challenging. Ji et al classified treatment methods into three types 6) : surgical BBA occlusion with ICA preservation (direct clipping, suturing, clipping after wrapping, or clipping after suturing), BBA occlusion by endovascular treatment with ICA preservation (coil embolization, stenting, flow-diverting stent insertion, or multiple overlapping stent insertion), and surgical or endovascular trapping of a parent artery combined with bypass. The incidence of complications is high regardless of the type of treatment, and no treatment method has been established.…”

“…However, there is no consensus regarding optimal treatment. 6) We report a patient in whom a ruptured BBA of the ICA was treated using two low-profile visualized intraluminal support (LVIS) stents (Microvention-Terumo, Tustin, CA, USA) without combining them with a coil.…”

Blister like aneurysm: a review about its endovascular management / Aneurismas Blister-Like: uma revisão sobre seu tratamento endovascular

“…However, considering that they are fragile and have a tendency to progress in size over a short period, primary coiling may be dangerous, given the lesion's wide neck, small size and weak wall that lacks collagenous tissue, particularly in the acute period. Despite some selective cases, coil embolization alone is not the optimal approach for treating ruptured BBAs (5,(18)(19)(20) .…”

Blister like aneurysm: a review about its surgical management / Aneurismas blister-like: uma revisão sobre seu manejo cirúrgico

“…Blister aneurysms are rare brain vascular lesions of uncertain pathogenesis (1) . Overall, they represent 0.3% -1.0% of all intracranial aneurysms and 0.9% -6.5% of all ruptured intracranial aneurysms (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11) . They are associated with high morbidity and mortality (9,12,13) .…”

“…The first description was made by Sundt and Murphey in 1969, where they anatomically defined the aneurysm as a shallow and broad based or semi fusiform focal protrusion (1,3,4,6,11,(14)(15)(16) . The most common location is the supraclinoid internal carotid artery (ICA) (1,(3)(4)(5)7,(10)(11)(13)(14)(15)(17)(18) . Now, it is possible to further classify blister aneurysms into four different groups: I -classic, lesions are small bulge on the parent artery with no neck.…”