Stent-in-stent technique for the management of blood blister-like basilar apex aneurysms

Blood blister-like basilar apex aneurysms are rare thin-walled vascular lesions with a poorly defined aneurysmal neck. We present two patients with ruptured blister aneurysms of the basilar apex who were treated using the stent-in-stent technique. Long-term follow-up showed persistent and complete occlusion of the aneurysms without radiographically or neurological complications. There is no optimal treatment of choice for the basilar apex blood blister-like aneurysms. Double- or triple-stent placement using the stent-in-stent technique can be a safe and feasible option for these uncommon and challenging intracranial aneurysms.

Stent-Assisted Coil Embolization of Ruptured Blood Blister-Like Aneurysm of the Basilar Artery: A Case Report and Literature Review

Objective

Blood blister-like aneurysms (BBA) often develop on the anterior wall of the internal carotid artery, and few cases have been reported at other sites. We report a case of stent-assisted coil embolization in the acute phase for a ruptured BBA of the basilar artery.

Case Presentation

A 53-year-old woman underwent emergency stent-assisted coil embolization for subarachnoid hemorrhage due to a ruptured BBA in the main trunk of the basilar artery. Seven months after the operation, cerebral angiography confirmed no recurrence and a good clinical course.

Conclusion

Stent-assisted coil embolization for BBA may be one treatment option.

Endovascular Temporary Balloon Occlusion for Microsurgical Clipping of Posterior Circulation Aneurysms

Based on the relationship between the posterior clinoid process and the basilar artery (BA) apex it may be difficult to obtain proximal control of the BA using temporary clips. Endovascular BA temporary balloon occlusion (TBO) can reduce aneurysm sac pressure, facilitate dissection/clipping, and finally lower the risk of intraoperative rupture. We present our experience with TBO during aneurysm clipping of posterior circulation aneurysms within the setting of a hybrid operating room (hOR). We report one case each of a basilar tip, posterior cerebral artery, and superior cerebellar artery aneurysm that underwent surgical occlusion under TBO within an hOR. Surgical exposure of the BA was achieved with a pterional approach and selective anterior and posterior clinoidectomy. Intraoperative digital subtraction angiography (iDSA) was performed prior, during, and after aneurysm occlusion. Two patients presented with subarachnoid hemorrhage and one patient presented with an unruptured aneurysm. The intraluminal balloon was inserted through the femoral artery and inflated in the BA after craniotomy to allow further dissection of the parent vessel and branches needed for the preparation of the aneurysm neck. No complications during balloon inflation and aneurysm dissection occurred. Intraoperative aneurysm rupture prior to clipping did not occur. The duration of TBO varied between 9 and 11 min. Small neck aneurysm remnants were present in two cases (BA and PCA). Two patients recovered well with a GOS 5 after surgery and one patient died due to complications unrelated to surgery. Intraoperative TBO within the hOR is a feasible and safe procedure with no additional morbidity when using a standardized protocol and setting. No relevant side effects or intraoperative complications were present in this series. In addition, iDSA in an hOR facilitates the evaluation of the surgical result and 3D reconstructions provide documentation of potential aneurysm remnants for future follow-up.

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

BACKGROUND

The optimal approach of blood blister-like aneurysms (BBAs) is debated. Wrapping has been reported to be an effective strategy, but artificial materials have often been used. In addition, perforator protection is difficult using this technique. In this case, we report a ruptured BBA of the left internal carotid artery (ICA) treated with a clip-reinforced wrapping technique using Y-shaped autologous temporalis fascia to protect the posterior communicating artery (PComA). The outcome was favorable.

CASE DESCRIPTION

A 48-year-old woman was admitted for subarachnoid hemorrhage. Digital subtraction angiography (DSA) revealed a BBA located opposite the PComA origin. A frontotemporal craniotomy was performed. The temporalis fascia was isolated from the temporalis muscle, and then tailored into a Y shape for the PComA to pass through. The diseased segment and the BBA were then wrapped by the Y-shaped temporalis fascia circumferentially. Two clips were applied to the fascia to reinforce the wrapping to fit snugly enough around the parent artery subsequently. DSA and computed tomography angiography scan postoperation showed that the BBA had not recurred, the supraclinoid segment of the left ICA had reconstructed well, and the PComA was unobstructed. The patient recovered without any sequelae during the 1-year follow-up period.

CONCLUSIONS

A clip-reinforced wrapping technique using Y-shaped temporalis fascia may be an effective method for treating BBAs located opposite the PComA origin. Long-term follow-up and large sample size studies, however, are necessary to validate this approach.

Mid A1 blister aneurysm presenting with subarachnoid hemorrhage: Case report and review

Blister aneurysms are uncommon and difficult-to-treat lesions. They are a substantial cause of morbidity and mortality when encountered. Here, we report a blister aneurysm of the mid A1 segment of the anterior cerebral artery presenting with diffuse basal subarachnoid hemorrhage (SAH). The aneurysm was treated by surgical clipping of the parent vessel. Postoperatively, there was no filling of the parent vessel or aneurysm. A treatment algorithm including direct surgical repair and flow diversion for ruptured blister aneurysms is described. A high level of suspicion should be maintained in the setting of angiographic-negative SAH with an asymmetrically diffuse pattern.

Suturing and Dural Wrapping for a Blood Blister-Like Aneurysm on the Supraclinoid Segment of the Internal Carotid Artery due to Dissection

BACKGROUND

Internal carotid artery (ICA) reconstruction is still the most effective treatment for a blood blister-like aneurysm (BBA) on the supraclinoid segment of the ICA, and clipping after wrapping has the most precise effects. However, the materials used are most often artificial. This study examined the use of autologous dura to replace the artificial materials used for wrapping after suturing a BBA.

CASE DESCRIPTION

A 38-year-old man was hospitalized for subarachnoid hemorrhage. Computed tomography angiography of the head and digital subtraction angiography showed a BBA on the dorsal supraclinoid segment of the ICA. A right frontotemporal craniotomy with extradural resection of the anterior clinoid was adopted. The aneurysm was trapped with temporary clips and was found to be derived from dissection of the ICA. The separated adventitia and vascular wall were sutured to reconstruct the vascular wall first, and then the dura was cut and shaped to wrap the supraclinoid segment of the ICA. The dura was sutured onto the ICA wall to prevent dislocation. A 6-month follow-up digital subtraction angiography review showed that the supraclinoid segment of the ICA was well reconstructed, the vascular cavity exhibited slight stenosis, and BBA did not recur. Postoperative follow-up magnetic resonance imaging showed satisfying images.

CONCLUSIONS

The method we adopted is new and showed satisfactory curative results, suggesting that ICA suturing with dura mater wrapping may become a method for the treatment of a BBA on the supraclinoid segment. The dura could potentially replace the artificial materials used for wrapping the ICA.

Technical nuances of subtemporal approach for the treatment of basilar tip aneurysm

Background:

Basilar tip aneurysms are one of the most complex vascular lesions to treat surgically because of their location, depth of the approach, and close proximity of vital neurovascular structures such as the mesencephalon, cranial nerves, perforating arteries to the thalamus. There are different surgical approaches utilized to reach basilar tip aneurysms, namely, pterional, pretemporal, orbitozygomatic, subtemporal, and anterior petrosectomy. Each of them has its advantages and limitations.

Methods:

In this paper, we present our personal experience with the use of subtemporal approach. The technique is described in detail including its nuances and potential pitfalls.

Results:

The subtemporal approach is indicated for basilar tip aneurysms located at the level of the floor of the sella turcica to 1 cm above the dorsum sellae.

Conclusion:

Subtemporal approach offers good surgical corridor for the management of these complex vascular lesions.

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

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.