J Cerebrovasc Endovasc Neurosurg.  2021 Sep;23(3):245-250. 10.7461/jcen.2021.E2020.12.001.

Slip Clip after successful microsurgery of a blister aneurysm: Should bypass always be the first option?

• Paiva ALC
• Aguiar GBd
• Flores JAC
• Veiga JCE

• KMID: 2520884
• DOI: http://doi.org/10.7461/jcen.2021.E2020.12.001

Abstract

Blood Blister-like aneurysms are intracranial non-saccular aneurysms with higher rupture risk due to its fragile wall. Diagnosis is performed in the acute phase of a subarachnoid hemorrhage. There are several treatment options based on reconstructive or deconstructive techniques. This paper aims to discuss the limitations of microsurgery clipping for a ruptured blister aneurysm. We report on a case of a female patient presented with a Fisher III subarachnoid hemorrhage. Cerebral angiography revealed an internal carotid artery blister aneurysm. Initially microsurgery clipping was successfully performed. However, after a few days the patient presented new subarachnoid hemorrhage. The new cerebral angiography showed growth of the previously clipped aneurysm, with displacement of the clip from the position adjacent to the artery. High-flow bypass was performed obtaining definitive treatment. This is a definitive approach for blister aneurysms. If microsurgery clipping is chosen, a strict follow-up is required due to the dynamic nature of this lesion and the chance of re-bleeding even after successfully clipping.

Keyword

Brain aneurysm; Cerebral revascularization; Subarachnoid hemorrhage; Microsurgery

Figure

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  Fig. 1. Pre-operative ICA angiogram showing a small broad-based aneurysm (arrow) at dorsal wall of the ICA. (A) Unsubstracted image. (B) 3D rotational angiography reconstruction. ICA, internal carotid artery.

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  Fig. 2. Microsurgical image after temporary clipping of the proximal (extracranial) and distal internal carotid artery. (A) The blister aneurysm covered by fibrin (arrow) is observed. (B) After partial removal of fibrin, it is possible to observe the blister aneurysmal neck (arrow). (C) After definite clipping.

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  Fig. 3. (A) Pre-operative ICA angiogram showing a small broad-based aneurysm at dorsal wall of the ICA. (B) Unsubstracted image and (C) Substracted image. Post-operative angiogram showing that the aneurysm grew back and pushed the clip. ICA, internal carotid artery.

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  Fig. 4. Right common carotid angiography after bypass, showing graft patency and complete vascularization of the right cerebral hemisphere. (A) frontal view. (B) Lateral view.

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