Blood blister aneurysm

Find out how Dr. Ehsan Mohammad Hosseini (Assistant Professor of Neurosurgery, Namazi Hospital, Shiraz University of Medical Sciences, Iran) treated a 55-year-old female patient suffering from a blister-like aneurysm in dorsal surface of right supra clinoid carotid.

Case

CASE PRESENTATION

Blood blister-like aneurysms (BBAs) include arterial vascular lesions from non-branching sites (dorsal or anterior wall).
Most classic location in the ICA.

Typical presentation: acute subarachnoid hemorrhage (SAH), mostly in younger female.
The classical morphology is small, hemispherical-shaped and bulging from non-branching sites on the ICA.

THE PHYSIOPATHOLOGY

Main hypothesis: Dissection, fragile fibrin layer in a focal arterial segment, and calcification changes.
The extremely fragile wall of BBAs makes the management complicated and risky.
More recently, the multilayer in-stent technique has been described for false aneurysms and for blister-like aneurysms.
Coiling of BBAs has been associated with a high intraprocedural rupture rate. The possibility of performing a parent vessel reconstruction appears to be a more physiological method to avoid intra-saccular treatments.

TREATMENT

Direct clipping, clipping after wrapping, coil embolization, stent-assisted coil embolization, multiple overlapping stents, flow-diverting stents, covered stents, and trapping with or without bypass.

CASE PRESENTATION

55 y/o lady with sudden onset severe headache.
GCS: 15.
FND: negative.
Past medical Hx: HTN.
Drug Hx: captopril.
Brain CT: diffuse SAH in basal cistern and Sylvian fissure with mild hydrocephalus.
Brain CTA: Blister Like Aneurysm in dorsal surface of right supra clinoid carotid.
DSA: confirm the diagnosis.

PLAN

FDS in right carotid.
Before stenting: loading dose of antiplatelet with ASA 650 mg and Clopidogrel 600 mg.
During stenting: 5000 unit heparin.
After stenting: for 3 month ASA 80 mg and Clopidogrel 75 mg daily and long life ASA 80 mg.

INITIAL BRAIN CT