Current status of the treatment of blood blister-like aneurysms of the supraclinoid internal carotid artery: A review

Abstract

Currently, the treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) is challenging and utilizes many therapeutic methods, including direct clipping and suturing, clipping after wrapping, clipping after suturing, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass. In these therapeutic approaches, the optimal treatment method for BBAs has not yet been defined based on the current understanding of BBAs of the supraclinoid ICA. Therefore, in this study, we aimed to review the literature from PubMed to discuss and analyze the pros and cons of the above approaches while adding our own viewpoints to the discussion. Among the surgical methods, direct clipping was the easiest method if the compensation of the collateral circulation of the intracranial distal ICA was sufficient or direct clipping did not induce stenosis in the parent artery. In addition, the clipping after wrapping technique should be chosen as the optimal surgical modality to prevent rebleeding from these lesions. Among the endovascular methods, multiple overlapping stents (≥3) with coils may be a feasible alternative for the treatment of ruptured BBAs. In addition, flow-diverting stents appear to have a higher rate of complete occlusion and a lower rate of retreatment and are a promising treatment method. Finally, when all treatments failed or the compensation of the collateral circulation of the intracranial distal ICA was insufficient, the extracranial-intracranial (EC-IC) arterial bypass associated with surgical or endovascular trapping, a complex and highly dangerous method, was used as the treatment of last resort.

Keywords: blood blister-like aneurysm; internal carotid artery; review.; supraclinoid segment; treatment.

Figure 1

Current effective and feasible therapeutic methods for treating BBAs of the supraclinoid ICA. A, Direct clipping. The left image shows a parent artery without stenosis and the right image shows stenosis of the parent artery. B, Clipping after wrapping. C, Multiple overlapping stents with coiling. D, Flow-diverting stent application. E, Surgical trapping with EC-IC bypass. F, Endovascular trapping with EC-IC bypass.

Figure 2

Direct clipping of BBAs of the supraclinoid ICAA, CT showing the SAH. B, DSA showing a small BBA of the supraclinoid ICA. C, Intraoperative image showing a small BBA on the supraclinoid ICA. D, The BBA was clipped directly.

Figure 3

Trapping with bypass of BBAs of the supraclinoid ICA. A, CT of the first SAH showing the hemorrhage in the suprasellar cistern. B, CTA showing a small BBA of the supraclinoid ICA. C, CT of the second SAH showing the intraventrical hemorrhage. D, DSA showing the BBA became bigger. E-F, Postoperative CTA showing that the BBA was trapped with EC-middle artery bypass.