Elsevier

World Neurosurgery

Volume 105, September 2017, Pages 470-477
World Neurosurgery

Original Article
Results of Early High-Flow Bypass and Trapping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery

https://doi.org/10.1016/j.wneu.2017.06.033Get rights and content

Objective

The aim of this study is to clarify the efficacy and safety of early surgery using trapping of the affected internal carotid artery (ICA) and high-flow bypass between the second portion of the middle cerebral artery and cervical external carotid artery with radial artery graft for ruptured blood blister-like aneurysms (BBAs) arising from the anterior wall of the ICA.

Methods

Medical charts of 16 consecutive patients (7 men and 9 women; mean, 59 years) with subarachnoid hemorrhage (World Federation of Neurosurgical Societies grade I, n = 2; grade II, n = 5; grade III, n = 2; grade IV, n = 4; grade V, n = 3) caused by ruptured BBA surgically treated between July 2010 and October 2015 were retrospectively reviewed. Eleven patients underwent acute surgery within 24 hours after the onset, whereas surgery was performed between 3 and 17 days after the onset because of referral delay or associated vasospasm in 5 patients. All patients underwent the same surgical procedure.

Results

Elimination of the BBA and patency of the bypass were achieved in all patients. Postoperatively, 2 patients showed small infarction in the Heubner artery area, and 2 others suffered symptomatic vasospasm, but no patient suffered infarction in the posterior communicating/anterior choroidal artery territories. Identically, no patient showed ischemic optic neuropathy. At the last follow-up (mean, 36 months), favorable clinical outcome (good recovery or mild disability in Glasgow Outcome Scale) was achieved in 14 (88%) of the patients without rebleeding or refilling of the aneurysms.

Conclusions

Early surgical repair of BBAs by trapping of the affected ICA with high-flow bypass is safe and effective treatment with satisfactory midterm outcome.

Introduction

Blood blister-like aneurysms (BBAs) arising from anterior wall of the internal carotid artery (ICA) are characterized by a fragile wall, a poorly defined neck, and a high tendency of fatal rebleeding during the acute period after subarachnoid hemorrhage (SAH). BBAs are a therapeutic challenge because the conventional treatment, including direct clipping or coiling, is usually very difficult and often causes the laceration or stenosis of the ICA and the regrowth or rebleeding of the aneurysm, resulting in high morbidity and mortality. Although the optimal treatment strategy for BBAs remains controversial, some authors have reported that trapping of the ICA combined with high-flow extracranial-intracranial (EC-IC) bypass is one of the most definite treatments for ruptured BBAs.1, 2, 3, 4, 5 However, the significance of acute intervention remains to be elucidated. The aim of this study is to clarify the efficacy and safety of trapping/high-flow bypass (HFB) for ruptured BBAs in early settings.

Section snippets

Patients and Clinical Assessment

All aspects of this study were approved by the Institutional Review Board of the Saitama Medical University International Medical Center (application number 16-229). We reviewed medical charts, imaging studies, and operative records of 16 consecutive patients with ruptured BBA treated at Saitama Medical University International Medical Center (Hidaka, Japan) between July 2010 and October 2015. The demographic and clinical characteristics of the patients are summarized in Table 1. The ages of

Results

A preoperative angiogram of all cases matched the definition of BBAs as described by Peschillo et al.6 Intraoperatively, the PCoA was found to be aplastic in 1 patient, and was anatomically preserved in 13 patients by an oblique trapping technique despite the PCoA being located below or just proximal to the aneurysm in 6 patients. In 2 patients, the PCoA was sacrificed because of considerably proximal localization (n = 1) and long extension of dissecting changes beyond the PCoA (n = 1).

Discussion

This study demonstrated that many patients with ruptured BBAs are tolerant of early surgery using trapping/HFB, even in poor-grade SAH. The procedure bears a chance of radical cure and low risk of ischemic complications of functional perforators. Development of delayed cerebral ischemia is comparable with ordinary clipping, preserving the parent artery.

Various surgical techniques, including parallel clipping,7, 8 encircle clipping,9, 10 clipping on wrapping,11, 12, 13, 14, 15 and trapping with

Conclusions

Early surgery with the HFB followed by ICA trapping is a safe and effective treatment with favorable midterm outcome for patients with ruptured BBA, even in high-grade SAH.

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      For complete occlusion of the lesion, surgical trapping is considered the most effective treatment2,5-7; however, it poses the risk of ischemic complications in the ICA and cerebral infarction as a result of cerebral vasospasm.2,3,5 Therefore, wrap-clipping,4,8 endovascular treatment,9,10 high-flow bypass,2,5,6,11 or a combination of these is indicated to preserve blood flow to the ICA. BLAs often occur proximally to C2 in the posterior communicating artery (PcomA).1,3

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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