Original ArticleResults of Early High-Flow Bypass and Trapping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery
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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2021, World NeurosurgeryCitation Excerpt :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.