Microsurgical Management of Ruptured Blood-blister Aneurysms (BBAs) of the Internal Carotid Artery (ICA) without Bypass: A Retrospective Single-center Study of 36 Patients over 20 Years

Background Microsurgical management of blood blister aneurysms of the internal carotid artery is challenging because of the special characteristics of these aneurysms. We reviewed our diverse surgical methods with long-term clinical and radiologic follow-up. Methods We retrospectively reviewed all patients with blood blister aneurysms presenting with subarachnoid hemorrhage that were treated with microsurgical obliteration between 1993 and 2017. Baseline characteristics of patients and aneurysms, surgical methods, and clinical and radiologic outcomes were analyzed. Results This study included 36 patients. The patients were treated using microsurgery with direct clipping (2 patients; 5.6%), cotton-assisted clipping (24 patients; 66.7%), wrapping-clipping (5 patients; 13.9%), or wrapping-clipping with suturing (5 patients; 13.9%). Complete occlusion of aneurysm was achieved in 34 of 36 patients (94.4%). Severe vasospasm developed in 18 of 36 patients (50%). Ischemic events occurred in 8 patients (22.2%), 2 of whom remained with severe disability. Regrowth or recurrence occurred in 1 patient (0.28%), which required additional stent-assisted coil embolization. Mean modified Rankin Scale score was 2.0 (median, 1.0; range, 0–4) at discharge and 1.3 (median, 1.0; range, 0–4) at the last follow-up. Conclusions Direct clipping is ideal if possible; however, direct clipping is challenging in most blood blister aneurysms. Assisted clipping with cotton is mainly used and could be an effective technique for reinforcement of the friable wall, with good clinical outcomes in our series. Moreover, suturing followed by wrapping-clipping is also useful for managing intraoperative rupture.