J Cerebrovasc Endovasc Neurosurg.  2017 Sep;19(3):171-183. 10.7461/jcen.2017.19.3.171.

The Blood Blister Like-aneurysm: Usefulness of Sundt Clip

• Park TJ
• Kim KH
• Cho JH

• KMID: 2393499
• DOI: http://doi.org/10.7461/jcen.2017.19.3.171

Abstract

OBJECTIVE
Blood blister-like aneurysm (BBA) is a kind of dorsal wall aneurysm and it is small, sessile, fragile and hazardous because of its high mortality and morbidity. Many challenges tried to establish the management or strategy. But so far, there is no optimal treatment of choice for the BBA. In this article, 17 cases of the ruptured BBA in one institute were analyzed retrospectively. The operative options were correlated with surgical and clinical outcomes.
MATERIALS AND METHODS
During 14 years between October, 2002 and October, 2016, 23 patients were treated for subarachnoid hemorrhage with ruptured dorsal wall aneurysms. There were various strategies for treatment and different outcomes revealed. BBA were 17 (74%) cases and 6 (26%) cases were saccular aneurysm. By excluding saccular aneurysm, BBA was sorted and classified with its morphological characteristics, and the outcome of treatment in each case investigated retrospectively.
RESULTS
Among 17 BBA-cases, 8 cases get microsurgical operation by Sundt clip. 5 cases get operation by conventional Yasargil clip, 1 case treated by Yasargil clip with wrapping, and 2 cases underwent endovascular management with coiling, and 1 case was managed by endovascular trapping of involved internal cerebral artery. Clinical outcomes were analyzed with modified Rankin Scale, Glasgow outcome scale and post-operative complications.
CONCLUSION
As the optimal management, operation using Sundt clip had much significance in treatment BBA. And, a thorough analysis of the angiography is essential to prepare for the treatment of BBA.

Keyword

Blood blister like aneurysm; Dorsal wall aneurysm; Subarachnoid hemorrhage; Sundt clip; Encircling clip; Yasargil clip

MeSH Terms

Aneurysm
Angiography
Blister*
Cerebral Arteries
Glasgow Outcome Scale
Humans
Mortality
Retrospective Studies
Subarachnoid Hemorrhage

Figure

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  Fig. 1 (A) Involved ICA was dissected and BBA exposed for clipping. There was atherosclerotic change on the ICA and wide based BBA was seen in the right side wall of the ICA. (B) Sundt clip was applied to BBA. (C), (D) Pre and post-operative cerebral angiography, there was stenotic change on the ICA, which Sundt clip was applied. The patency of posterior communicating artery was maintained. ICA = internal carotid artery; BBA = blood blister-like aneurysm.

• 

  Fig. 2 Direct clipping of BBA. (A) The ICA BBA was exposed before clipping, (B) Rt.angled Yasargil clip was applied to BBA. The blade of clip was applied along the ICA trunk. And the normal vessel wall of ICA was caught by clip. (C) Preoperative 3-dimensional angiographic reconstruction. (D) Postoperative angiographic image in 5days after. The ICA trunk has stenotic change in diameter. Rt. Angled 5mm and bent 6.1 mm Yasargil clips were applied. ICA = internal carotid artery; BBA = blood blister-like aneurysm.

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  Fig. 3 (A) Yasargil clip was applied on wrapping with Teflon material. (B) Post-operative 3-dimensional angiographic reconstruction of wrapped BBA in ICA. BBA = blood blister-like aneurysm; ICA = internal carotid artery.

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  Fig. 4 Endovascular trapping of involved ICA, (A) pre-operative 3-dimensional angiographic reconstruction. (B) Rt. ICA occlusion test in cerebral angiography, for evaluation of possibility of Trapping. (C), (D) Post-operative cerebral angiography, after trapping of involved ICA. Despite without Rt. ICA blood flow, the patency of Rt. MCA and Rt. Ophthalmic artery was maintained. ICA = internal carotid artery; MCA = middle cerebral artery.

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