Blood blister-like aneurysms (BBA) were described for the first time in the 1990s, as small hemispherical bulges arising from a very fragile arterial wall. Until 2008, it was thought that this type of aneurysm almost exclusively affected the internal carotid artery, in particular, its dorsal portion. Subsequently, it was discovered that a BBA may also be present on the anterior communicating artery and on the vessels of the posterior cranial fossa. However, we found no reports in English-language literature of BBA arising from the middle cerebral artery (MCA). In this article, we present three cases of MCA BBA and discuss the unique diagnostic and therapeutic aspects of this vascular lesion. In our retrospective, multicenter review of 1330 patients with non-traumatic subarachnoid hemorrhage admitted to our services from 2000 to 2013, we found three cases (all in men) of MCA BBA. The patients’ outcome was assessed using the modified Rankin scale. All three patients underwent angio-computed tomography, which did not reveal any aneurysms. Digital subtraction angiography performed within 24–48 h after admission, in all cases, demonstrated a very small aneurysm (<2 mm), with a triangular shape and abroad base, at non-branching sites of MCA. All the aneurysms were treated: one by wrapping + clipping, one by wrapping + flow-diverter stent, and one with coils. At the time of surgery, the aneurysms appeared on the surface of the parent artery without any involvement of the branches. All presented as blister-like aneurysms that were thin-walled and lacked a surgical neck. At the time of discharge, the outcome was good in one patient and poor in the other two. Our cases demonstrate that BBA can also arise from the MCA, despite the lack of previous reports of this occurrence; a BBA should be suspected, particularly in cases of non-perimesencephalic subarachnoid hemorrhage in which the presence of a MCA aneurysm is suspected but not revealed by digital subtraction angiography or angio-computed tomography.
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The authors thank Antonio Santodirocco for the editing assistance.
Mustafa K. Baskaya, Madison, USA
This report by Peschillo et al. is an important contribution to the literature in supporting the idea that BLA can occur at any intracranial arterial location. Although BLA are mostly located at the anteromedial aspect of the supraclinoid internal carotid artery (ICA), other reported localizations for BLA include the basilar artery1, the anterior communicating artery2, and the middle cerebral artery (MCA)3. This report also deserves special attention because it may shed light on the current nomenclature used to describe BLAs. Unfortunately, the term “blister” is commonly and mistakenly used for any aneursym at any location based on its size. Angiographic appearance, size, and location (non-branching side) are not suficient for an accurate diagnosis of BLAs. I have recently encountered a BLA of the MCA bifurcation and our initial impression was that this aneurysm was a ruptured saccular aneurysm4. On the other hand, I have also encountered aneurysms arising from the non-branching side of the supraclinoid ICA, which upon exploration, were actually true saccular aneurysms. In reality, these BLAs are different from saccular or dissecting aneurysms and their hallmark is the lack of any arterial wall.
Treatment of these aneurysms is challenging, regardless of the method used, but they are prone to grow and rupture without treatment. Treatment in the acute period after hemorrhage reduces the risk of re-bleeding, which is substantial in BLAs. The main goal of treatment should be to eliminate the diseased segment of the artery. Fundamentally, this goal can be achieved by open surgical or endovascular means. Surgical treatment options include trapping (with clipping, balloon occlusion, or coiling) with or without bypass, direct clipping, wrapping, clip placement with wrapping, and direct arterial suturing/stapling. Endovascular options include primary coil embolization with or without stents or flow diverting stents. In my opinion, ideal treatment should be trapping with bypass, which provides definite elimination of the diseased segment of the artery and restoration of flow. It is advisable, however, that an experienced cerebrovascular surgeon, with detailed knowledge of the vascular anatomy and familiarity with different bypass options, should perform this procedures.
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2. Andaluz N, Zuccarello M. Blister-like aneurysms of the anterior communicating artery: a retrospective review of diagnosis and treatment in five patients. Neurosurgery. 2008;62:807–62
3. Pistocchi S, Blanc R, Bartolini B, Piotin M. Flow diverters at and beyond the level of the circle of Willis for the treatment of intracranial aneurysms. Stroke. 2012;43:1032–1038
4. Cıkla U, Sadighi A, Bauer A, Başkaya M. Fatal ruptured blood blister-like aneurysm of middle cerebral artery associated with Ehlers–Danlos syndrome type VIII (periodontitis type). JNSR accepted manuscript ID 14-Jan-0011-R)
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Peschillo, S., Missori, P., Piano, M. et al. Blister-like aneurysms of middle cerebral artery: a multicenter retrospective review of diagnosis and treatment in three patients. Neurosurg Rev 38, 197–203 (2015). https://doi.org/10.1007/s10143-014-0581-3
- Flow diverter stent
- Blister-like aneurysm
- Middle cerebral artery
- Endovascular treatment
- Brain aneurysm