Surgical treatment of blood blister–like aneurysms of the supraclinoid internal carotid artery with extracranial–intracranial bypass and trapping

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Abstract
Object: Blood blister–like aneurysms (BBAs) arise from the supraclinoid internal carotid artery (ICA) at non-branching sites. These aneurysms are challenging to treat primarily with either surgical clip placement or endovascular therapy. The authors describe a series of 4 patients who presented with high-grade subarachnoid hemorrhage (SAH) due to a BBA, which was treated with an extracranial–intracranial (EC–IC) bypass followed by trapping of the aneurysm. Methods: Four patients presented with SAH due to a BBA of the ICA. Three of these patients were treated with an endovascular procedure; following the vasospasm period, definitive treatment with EC–IC bypass followed by trapping of the aneurysmal parent vessel was performed. Results: Two of the patients who were treated endovascularly suffered rebleeding prior to bypass and trapping. Three of the 4 patients had a good outcome (modified Rankin Scale Score 1 or 2), and 1 patient who suffered 2 episodes of rebleeding died. Conclusions: Treatment of BBAs of the ICA remains difficult, particularly in the setting of high-grade SAH. Patients with this challenging condition often require multiple procedures and have a high incidence of rebleeding. Definitive treatment of these aneurysms consists of EC–IC bypass and surgical or endovascular trapping.