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      Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results

      research-article
      Author(s): 1 , 2 , ∗ , 1 , 3 , 1 , 4 , 3 , 1 , 2 , 5
      Publication date (Electronic):
      Journal: World Neurosurgery: X
      Publisher: Elsevier
      Keywords: Blood blister-like aneurysm, Clipping on crossed wrapping, Clipping on wrapping, Direct surgery, Internal carotid artery aneurysm, 3D-CTA, Three-dimensional computed tomographic angiography, AchA, Anterior choroidal artery, BBA, Blood blister-like aneurysm, COCW, Clipping on crossed wrapping, COW, Clipping on wrapping, CT, Computed tomography, IC, Internal carotid, ICA, Internal carotid artery, IC-BBAs, BBAs of the ICA, mRS, Modified Rankin Scale, PcomA, Posterior communicating artery, SAH, Subarachnoid hemorrhage

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          Abstract

          Background

          We have been performing the clipping on crossed wrapping (COCW) method using 2 strips of cotton on patients with an internal carotid artery blood blister-like aneurysm (IC-BLA). This method is reliable in preventing the clips from slipping off and the aneurysm walls from being damaged during clipping, and it enables more appropriate and safer clipping. Here we report the technical details of this method and the long-term outcomes of patients receiving this procedure.

          Methods

          Fifteen of 1275 (1.5%) patients with a ruptured cerebral aneurysm who received treatment at the Saiseikai Kumamoto Hospital during the period from January 1, 1999, to December 31, 2016, had an IC-BLA. All 15 patients were treated with COCW, except for the first patient, who was treated using a single strip of cotton. The long-term outcome of the treatment was analyzed.

          Results

          The mean follow-up period was 74 months. The first patient experienced rerupture of an aneurysm 10 days after the operation. No complications or regrowth of an aneurysm were observed in the remaining 14 patients during the follow-up period, except for 1 patient who received a reoperation for the regrowth of an aneurysm. As the final outcome, the numbers of patients with a Modified Rankin Score of 0, 3, and 6 were 13, 1, and 1, respectively.

          Conclusions

          It is suggested that COCW is a treatment that enables safe and long-term management of lesions in IC-BLAs.

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          Most cited references58

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          Aneurysms at nonbranching sites in the surpaclinoid portion of the internal carotid artery: internal carotid artery trunk aneurysms.

          A Ogawa, Annie Ogasawara, Stephanie M. Suzuki (2000)
          Aneurysms at nonbranching sites in the supraclinoid internal carotid artery (ICA), known as blood blister-like aneurysms or ICA anterior or dorsal wall aneurysms, are not well understood. To clarify this clinical entity, 7408 patients with subarachnoid hemorrhage who were treated during a 5-year period were analyzed. Forty-eight patients had aneurysms that were intraoperatively confirmed to be located at a nonbranching site in the supraclinoid portion of the ICA. Neuroradiological and clinicopathological features and outcomes were studied. The aneurysms were divided into the "blister type," with a blood blister-like configuration and fragile walls, and the "saccular type," with a saccular configuration and a relatively firm neck, like ordinary berry aneurysms. The most frequent origin was the anteromedial wall for both types. ICA dissection was associated only with the blister type, and hypertension was more frequent with the blister type (P = 0.0978). The preoperative conditions of the patients were the same, but the outcomes for patients with blister-type aneurysms were worse, because of frequent intra- and postoperative aneurysmal bleeding. Saccular-type aneurysms were safely clipped. Treatment of blister-type aneurysms by clipping on wrapping material achieved good results, but ICA trapping (P = 0.0952), clipping (P = 0.0146), and wrapping (P = 0.0110) were associated with much worse results. Blister-type and saccular-type aneurysms have different shapes and wall characteristics. The saccular type can be treated by clipping, whereas the blister type requires clipping on wrapping material. ICA trunk aneurysms may be a better designation to express the diversity of these aneurysms, rather than ICA blood blister-like or anterior or dorsal wall aneurysms.
          Article 0 comments Cited 49 times – based on 0 reviews     Review now
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            Blood blister-like aneurysms of the internal carotid artery trunk causing subarachnoid hemorrhage: treatment and outcome.

            Juha Hernesniemi, Torstein Meling, Angelika Sorteberg … (2008)
            The object of this study was to evaluate cases of subarachnoid hemorrhage (SAH) from ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) trunk. The authors performed a single-center, retrospective study. Data analyzed were patient age, sex, Hunt and Hess grade, Fisher grade, time from SAH to hospitalization, aneurysm size and location, collateral capacity of the circle of Willis, time from hospitalization to aneurysm repair, type of aneurysm repair, complications, and Glasgow Outcome Scale (GOS) score at follow-up. A total of 211 patients suffered SAH from ICA aneurysms. Of these, 14 patients (6.6%) had ICA trunk BBAs; 6 men and 8 women. The median age was 47.8 years (range 29.9-67.7 years). The Hunt and Hess grade was IV or V in 7 cases, and SAH was Fisher Grade 3 + 4 in 6. All aneurysms were small (< 1 cm), without relation to vessel bifurcations, and usually located anteromedially on the ICA trunk. Three patients were treated with coil placement and 11 with clip placement. Of the 7 patients in whom the ICA was preserved, only 1 had poor outcome (GOS Score 2). In contrast, cerebral infarcts developed in all patients treated with ICA sacrifice, directly postoperatively in 2 and after delay in 5. Six patients died, 1 survived in poor condition (GOS Score 3; p < 0.001). Internal carotid BBAs are rare, small, and difficult to treat endovascularly, with only 2 of 14 patients successfully treated with coil placement. The BBAs rupture easily during surgery (ruptured in 6 of 11 surgical cases). Intraoperative aneurysm rupture invariably led to ICA trap ligation. Sacrifice of the ICA within 48 hours of an SAH led to very poor outcome, even in patients with adequate collateral capacity on preoperative angiograms, probably because of vasospasm-induced compromise of the cerebral collaterals.
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              Blood blisterlike aneurysms of the internal carotid artery.

              A Uchino, Ken Tabuchi, Eniola Abe … (1998)
              An aneurysm arising from the anterior wall of the internal carotid artery (ICA) is a poorly understood entity. A small hemispherical bulge from the anterior wall of the ICA, which is called a "blood blisterlike aneurysm" (BBA), may be confused with a tiny berry aneurysm although the clinical features are distinctly different. This paper summarizes the clinical course of patients with this lesion to clarify the nature of the BBA. Six patients with BBAs who presented with subarachnoid hemorrhage (SAH) are described. In all patients, the initial angiogram obtained soon after SAH showed only a small bulge from the anterior wall of the ICA. In three of the six patients this bulge had progressed to a saccular appearance within a few weeks. The wall of the lesion was so thin and fragile that the aneurysm ruptured at the base during clipping or within a few hours after clipping in two patients. From the authors' experience, as well as a review of the literature, which includes an autopsy study of similar cases, it is inferred that these lesions are focal wall defects covered only with thin fibrous tissue and that they are therefore not true aneurysms. Direct clipping often causes laceration of the lesion, whereas complete wrapping or clipping after wrapping is effective, but may fail to prevent growth of the aneurysm. Endovascular occlusion of the cervical ICA with or without bypass surgery, which is less risky than direct surgery, is another option.
              Article 0 comments Cited 40 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Toru Nishi
                Journal
                Journal ID (nlm-ta): World Neurosurg X
                Journal ID (iso-abbrev): World Neurosurg X
                Title: World Neurosurgery: X
                Publisher: Elsevier
                ISSN (Electronic): 2590-1397
                Publication date PMC-release: 04 January 2019
                Publication date Collection: April 2019
                Publication date (Electronic): 04 January 2019
                Volume: 2
                Electronic Location Identifier: 100005
                Affiliations
                [1 ]Department of Neurosurgery, Stroke Center, Saiseikai Kumamoto Hospital, Kumamoto, Japan
                [2 ]Department of Neurosurgery, Sakurajyuji Hospital, Kumamoto, Japan
                [3 ]Department of Neurosurgery, Kumamoto General Hospital, Kumamoto, Japan
                [4 ]Department of Neurosurgery, Arao City Hospital, Kumamoto, Japan
                [5 ]Department of Neurosurgery, Saiseikai Misumi Hospital, Kumamoto, Japan
                Author notes
                [∗ ]To whom correspondence should be addressed: Toru Nishi, M.D., Ph.D. tnishi2@ 123456me.com
                Article
                Publisher ID: S2590-1397(18)30005-X Publisher ID: 100005
                DOI: 10.1016/j.wnsx.2018.100005
                PMC ID: 6580898
                PubMed ID: 31218280
                SO-VID: 2f29c423-2599-4e60-987b-5756b0beb0c1
                Copyright © © 2019 The Author(s)
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 18 October 2018
                Date accepted : 13 December 2018
                Categories
                Subject: Original Article

                Keywords: blood blister-like aneurysm,clipping on crossed wrapping,clipping on wrapping,direct surgery,internal carotid artery aneurysm,3d-cta, three-dimensional computed tomographic angiography,acha, anterior choroidal artery,bba, blood blister-like aneurysm,cocw, clipping on crossed wrapping,cow, clipping on wrapping,ct, computed tomography,ic, internal carotid,ica, internal carotid artery,ic-bbas, bbas of the ica,mrs, modified rankin scale,pcoma, posterior communicating artery,sah, subarachnoid hemorrhage
                Data availability:
                Keywords: blood blister-like aneurysm, clipping on crossed wrapping, clipping on wrapping, direct surgery, internal carotid artery aneurysm, 3d-cta, three-dimensional computed tomographic angiography, acha, anterior choroidal artery, bba, blood blister-like aneurysm, cocw, clipping on crossed wrapping, cow, clipping on wrapping, ct, computed tomography, ic, internal carotid, ica, internal carotid artery, ic-bbas, bbas of the ica, mrs, modified rankin scale, pcoma, posterior communicating artery, sah, subarachnoid hemorrhage

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