Changing treatment strategy from clipping to radial artery graft bypass and parent artery sacrifice in patients with ruptured blister-like internal carotid artery aneurysms.

Background: Blood blister-like aneurysms (BBAs) are aneurysms with ill-defined fragile necks arising from an internal carotid artery (ICA) and associated with high mortality.

Objective: To describe strategies and outcomes in patients in whom radial artery (RA) graft bypass with ICA sacrifice was considered as the primary treatment during the acute phase of subarachnoid hemorrhage.

Methods: The authors analyzed the clinical records of 20 patients who were treated between 2004 and 2011 at their hospital and affiliate institutions.

Results: A majority of the patients were treated during the acute phase (<24 hours, n = 15). A favorable outcome was achieved in 18 (90%) patients. The treatment strategies used were as follows: (1) ICA trapping/external carotid artery (ECA)-RA-middle cerebral artery (MCA) bypass (n = 13), (2) ICA trapping/superficial temporal artery-MCA bypass (n = 2), (3) aneurysm clipping with RA-MCA temporary bypass (n = 3), (3) aneurysm clipping with proximal ICA ligation and ECA-RA-MCA bypass (n = 1), and (4) direct clipping (n = 1). Postoperative infarction was observed in 6 patients and was ascribed to vasospasm (n = 1), retrograde thrombosis associated with trapping (n = 2), and reasons unrelated to the surgical procedures (n = 3).

Conclusions: Trapping with RA graft bypass demonstrated favorable results in patients with internal carotid BBAs. Although trapping/RA graft bypass is a definitive treatment for BBAs located proximal to the origin of the posterior communicating artery, some distal BBAs preclude ICA trapping to spare the perforating arteries.