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Blister-like aneurysms—a diagnostic and therapeutic challenge

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Abstract

Blister-like internal carotid artery (ICA) aneurysms are known for their fragile and thin-walled morphology associated with a high risk of intraprocedural rupture. Neurosurgical and endovascular options are illustrated on three exemplary cases reviewing the diagnostic and therapeutic implications of these special aneurysms. A 49-year-old woman was admitted with subarachnoid hemorrhage (SAH) in which angiography showed a broad-based, small bulging ectasy of the terminal ICA segment. On the attempt of surgical clipping, the aneurysm ruptured leaving a tear in the ICA. After temporary clipping, the rims of the tear were approximated by sutures. Sufficient closure of the remaining leakage was achieved by circumferential wrapping which was secured by two clips. Postoperative angiography confirmed stenosis of the tightened ICA and patient recovered without neurological deficit. Surgical attempt on a second case with bulging of the C4-segment topped by a small aneurysm was fatal due to extensive laceration of the basal ICA intraoperatively. Endovascular stenting was the choice of treatment in a third SAH patient in which angiography was suspicious of a blister-like ICA aneurysm. Six-month follow-up was uneventful; the patient recovered well and further growth of bulging was not seen. Reviewing the literature, blister-like aneurysms tend to arise at uncommon sites not located at the arterial branches. Small and broad-based bulges with or without true saccular aneurysms have to be assessed as characteristic features of blister-like aneurysms. Rupture of the aneurysm involving the carrying artery has to be considered during therapeutic attempts, in which urgent strategies have to be kept in reserve preventing fatal outcome. Blister-like aneurysms is a hazardous affair for neurosurgeons and neuroradiologists as their fragile structure most likely will lead to intraoperative rupture. If endovascular treatment is not promising, wrapping and revascularization techniques come true to still be an important part of the neurosurgeons toolbox for reconstructing a vessel lumen and preserving a sufficient cerebral blood flow.

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Authors and Affiliations

  1. Universitätsklinikum Hamburg Eppendorf, Neurochirurgische Klinik, Hamburg, Germany

    Jan Regelsberger, Jakob Matschke, Ulrich Grzyska, Thorsten Ries, Jens Fiehler, Johannes Köppen & Manfred Westphal

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  1. Jan Regelsberger
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  2. Jakob Matschke
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  3. Ulrich Grzyska
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Correspondence to Jan Regelsberger.

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Comments

Siamak Asgari, Ingolstadt, Germany

The authors present a very small series of three patients with so-called blister-like aneurysms of the supraclinoidal internal carotid artery (ICA). In two patients, intraoperative rupture occurred followed by death of one of them. The third patient underwent interventional procedure by ICA stenting with good clinical outcome. A review of the literature was given. However, I am not sure that a subgroup of such blister-like aneurysms exists. Over my own 13-years period experience as a neurovascular surgeon, I remember three blister-like thin-walled aneurysms of the ICA (one paraclinoidal, two supraclinoidal), one of the anterior communicating artery (multi-blister), one of the A1 segment, and one of the vertebral artery. In all these cases, primary clip ligation of the aneurysm with preservation of the parent arteries without rupture-like complications was achieved. I agree that neuroradiological intervention has to be discussed in all these cases.

Ernst Delwel, Rotterdam, The Netherlands

The authors give us a well-written and very detailed description of a rare type of intracranial aneurysm, the blister-like aneurysm. An extensive overview of the literature is given and the authors describe three of their own cases. The characteristic features of the aneurysm are the location at an uncommon site of the parent vessel, not at the site of a branching artery, their broad based bulging with or without true saccular aneurysm formation at radiological imaging and there very fragile wall, carrying a high risk of spontaneous rupture leading to SAH or rupture during surgical or endovascular intervention. The pathogenesis of blister-like aneurysms still remains unclear.

The radiological diagnosis of a blister-like aneurysm is not in all cases clear and without any doubt. Endovascular treatment is the first and safest option however, due to the fragile wall of the aneurysm, coiling carries an increased risk of rupture during the intervention. In case endovascular strategies are not practicable for technical reasons, surgical treatment is indicated. I agree with the authors that in case of planned surgery, several pre- or preoperative measures should be taken as an emergency plan, like ordering for special encircling clips for parent vessel reconstruction, preparing for early proximal control and being prepared to perform a high-flow bypass prior to trapping of the aneurysm and intra-operative SSEP and MEP monitoring. Whenever possible, one should consider referring patients with a probably ruptured blister-like aneurysm to a neurovascular center with a high standard of experience and expertise.

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Regelsberger, J., Matschke, J., Grzyska, U. et al. Blister-like aneurysms—a diagnostic and therapeutic challenge. Neurosurg Rev 34, 409–416 (2011). https://doi.org/10.1007/s10143-011-0313-x

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