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Changing Treatment Strategy From Clipping to Radial Artery Graft Bypass and Parent Artery Sacrifice in Patients With Ruptured Blister-Like Internal Carotid Artery Aneurysms

Kazumata, Ken MD*; Nakayama, Naoki MD*; Nakamura, Toshitaka MD; Kamiyama, Hiroyasu MD§; Terasaka, Shunsuke MD*; Houkin, Kiyohiro MD*

doi: 10.1227/NEU.0000000000000076
Technique Assessment

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).

CONCLUSION: 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.

ABBREVIATIONS: BBA, blister-like aneurysm

DCI, delayed cerebral ischemia

ECA, external carotid artery

ICA, internal carotid artery

MCA, middle cerebral artery

mRS, modified Rankin scale

Pcom, posterior communicating

RA, radial artery

SAH, subarachnoid hemorrhage; STA, superficial temporal artery

*Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan

Sapporo Azabu Neurosurgical Hospital, Sapporo, Japan

§Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan

Correspondence: Ken Kazumata, MD, Department of Neurosurgery, Hokkaido University Graduate School of Medicine, North 15 West 7, Kita, Sapporo 060-8638, Japan. E-mail:

Received April 09, 2013

Accepted June 25, 2013

Copyright © by the Congress of Neurological Surgeons