Accepted Manuscript Blister like aneurysms: report of successful surgical treatment of consecutive cases and review of literature Felix Hendrik Pahl, PhD, Matheus Fernandes de Oliveira, MD, Marcos de Queiroz Teles Gomes, MD, Alberto Carlos Capel Cardoso, PhD, José Marcus Rotta, MD PII:

S1878-8750(16)00107-8

DOI:

10.1016/j.wneu.2016.01.025

Reference:

WNEU 3625

To appear in:

World Neurosurgery

Received Date: 4 November 2015 Revised Date:

31 December 2015

Accepted Date: 4 January 2016

Please cite this article as: Pahl FH, de Oliveira MF, Gomes MdQT, Cardoso ACC, Rotta JM, Blister like aneurysms: report of successful surgical treatment of consecutive cases and review of literature, World Neurosurgery (2016), doi: 10.1016/j.wneu.2016.01.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Blister like aneurysms: report of successful surgical treatment of consecutive cases and review of literature. Felix Hendrik Pahl PhD1,2,3, Matheus Fernandes de Oliveira MD1,2,3, Marcos de Queiroz Teles

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Gomes MD 2,3, Alberto Carlos Capel Cardoso PhD 2,3, José Marcus Rotta MD1.

1 -Department of Neurosurgery, Hospital do Servidor Público Estadual de São Paulo,

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IAMSPE, São Paulo-Brazil.

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3- DFV Neuro - São Paulo – Brazil

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2- Department of Neurosurgery, Hospital Sirio Libanês, São Paulo-Brazil.

*Corresponding author:

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Matheus Fernandes de Oliveira [email protected]

Rua Loefgreen, 700, Vila Clementino São Paulo

ZIP CODE 04040-000 Telephone number: 55 11 99976-3501

Fax Number: 55 11 3259-8577

ACCEPTED MANUSCRIPT Abstract Introduction. Blister-like aneurysms (BAs) are usually defined as arterial lesions arising from non-branching sites on intracranial arteries. Due to specific peculiarities such as different pathophysiology, fragility of aneurismal wall, high risk of intraoperative bleeding and a high

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probability of losing parent vessel patency, their current treatment persists controversial, being endovascular and surgical options applicable and reported. Methods. From 2006 to 2015 (10 years), a total of 7 aneurysms in 6 patients were treated. We retrospectively reviewed the

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records of these patients to analyze clinical pictures and outcomes, which are expressed as modified Rankin Scale. Results. In our sample of 7 aneurysms in 6 patients, all BAs were

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successfully treated (complete exclusion in 100% on follow-up angiography). A good outcome (mRs of 0) was achieved in all patients, with no difference related to aneurysm size and location. There was no mortality. Conclusion. Surgical treatment of BAs may be effective and

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with acceptable complications and outcomes.

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Key words: intracranial aneurysm; treatment; surgery; endovascular

ACCEPTED MANUSCRIPT Introduction Blister-like aneurysms (BAs) are usually defined as arterial lesions arising from nonbranching sites on intracranial arteries[1,2,3]. They are rare, representing approximately 0.9– 6.5% of all ICA aneurysms, 1% of all intracranial aneurysms, and 0.5–2% of all ruptured

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aneurysms[4,5].

BAs can occur in any intracranial artery, but are more frequent in the supraclinoid internal carotid artery. In this site, a BA typically appears as small, hemispherical bulge at the

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anterior or anteromedial wall[1,2,3,7,8]. The pathophysiology of BAs involves hemodynamic

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stress or arterial dissections, and they generally present as subarachnoid hemorrhage (SAH)[4,5]. Due to a variety of unique characteristics, such as distinct pathophysiology, fragility of the aneurismal wall, sometimes challenging diagnosis, high risk of intraoperative bleeding, small size, and high probability of losing parent vessel patency, treatment of BAs remains controversial. Endovascular and surgical options are available and have been reported[20-32].

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The purpose of this paper is to present our experience with surgical treatment of BAs and compare them to endovascular and surgical results previously reported in the literature.

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Method

From 2006 to 2015 (10 years), a total of seven blister aneurysms in six patients were

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treated consecutively. We retrospectively reviewed the records of these patients to analyze clinical pictures and outcomes, which are expressed as modified Rankin scores (mRs). All patients experienced SAH, and all underwent craniotomy and aneurysm clipping. In

one patient, a stent was placed after clipping because of residual aneurysm. No unruptured blister aneurysm was diagnosed and treated during study period. Categorical data are described as percentages. Results

ACCEPTED MANUSCRIPT Results are summarized in Table 1 and 2. Sample data The sample profile is described in Table 1. The gender distribution was homogeneous.

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One male patient presented with two aneurysms. Overall, age ranged between 33 and 64 years, with a mean of 50.2 years (55 years among men, 45.3 years among women).

Five aneurysms (71.4%) were located on the ICA (Figure 1) (two of them in the same

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patient), one (14.3%) was an anterior cerebral artery (ACA) aneurysm (Figure 2), and one (14.3%) was a basilar artery (B) aneurysm (Figure 3). Initial diagnostic angiography was

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negative in two patients (33%). In patient 4, repeat angiography revealed a small aneurysm within 1 week of SAH. In patient 6, two initial angiographies performed over the course of a week were negative. The aneurysm was only found on repeat angiography 2 months later. Aneurysm size ranged from 2 to 7 mm (mean, 4 mm). All patients presented with SAH:

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two (33.3%) with a Fisher classification of 2, three patients (50%) with a score of 3, and one patient (16.6%) with a score of 4. Four patients (66.6%) presented with a Hunt and Hess score of 2 and two (33.3%) presented with a Hunt and Hess score of 3.

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Surgical technique

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Surgical outcomes are described in Table 2. An ipsilateral pterional approach was employed in five patients with BA in the anterior

circulation, while a presigmoid approach was used in the sole patient harboring a basilar aneurysm.

All patients but were treated with direct aneurysm clipping. We did not apply wrapping in any case, although we were prepared to use it if necessary. In patient 4, whose aneurysm was located on the ACA, a residual aneurysm was treated with placement of an Enterprise stent.

ACCEPTED MANUSCRIPT Bypass was not required in any case in these series, although we were prepared to perform it if necessary. Complications

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Intraoperative bleeding occurred in three patients (50%), and was controlled with temporary trapping and clip placement including part of the wall of the parent artery. Asymptomatic arterial stenosis occurred in two patients (33.3%).

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Outcome

The length of follow-up ranged from 1 to 9 years (mean, 3.83).All aneurysms were

Rankin Scale (mRs) of 0 or 1. Discussion Generalization

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completely excluded, including at late follow-up. All patients were discharged with a modified

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BAs were first described in 1969 by Sundt and Murphey[30], but the term “blister” was introduced in 1988 by Takashi[3]. BAs are uncommon aneurysms composed of a thin layer of adventitia. Mizutani et al[19] classified BAs as a subtype of non atherosclerotic dissecting

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aneurysms. Day et al[7] speculated that BAs represent a focal dissection, resembling that seen in

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the proximal intracranial vertebral artery near the origin of the posteroinferior cerebellar artery. Not only has it been hypothesized that BA might represent a type of dissection, but an association with ICA dissection namely, as a causative factor of BA – has been reported. Comorbid arterial dissection has been reported in 40 to 89% of cases[5,7,8,9,10]. The classical morphology of BA is that of a small, hemispherical bulge arising from non-branching sites on the ICA[11-22]. BAs are typically diagnosed after a bleed, because their small size means they are frequently missed on routine angiographic investigation. Patients typically present with subarachnoid hemorrhage (SAH), and the affected population is

ACCEPTED MANUSCRIPT characteristically younger than patients with saccular aneurysms. In some cases, more than one normal angiography may be obtained until the diagnosis is achieved. Female predominance and right-sided ICA predominance have been reported, as have associations with hypertension and

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arteriosclerosis[4,5,6,7,8,9,10]. Due to difficulty in establishing the diagnosis, a very high risk of intraoperative aneurysm rupture, and a high probability of losing parent vessel patency, treatment of BAs remains challenging. These aneurysms grow rapidly in a short time and rupture easily,

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especially during surgery[7,8].

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Treatment modalities

Treatment strategies include surgical, endovascular, and combined approaches[8,9,10,11]. The surgical options are direct lesion clipping, wrapping or encircling techniques, and bypass surgery[10,11,12,13,14,15,16,17,18]. Endovascular options include coiling and several types of stents[18,19,20,21,22,23,24,25,26,27,28,29,30]. The main surgical issue is the extremely fragile nature of the

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walls and the usually large arterial defect. Direct clipping could lead to avulsion of the aneurysm, or even to obliteration of the parent vessel.

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Microsurgery is an applicable option. Lee et al[14] treated 18 patients of whom 15 underwent wrapping with cellulose fabric and clipping and each of the remaining three

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underwent direct clipping, suturing, or trapping. The overall outcome was mRS 1 in 11 patients (78.0%). McLaughlin et al[16] treated seven cases presenting with SAH. There was no intraoperative bleeding and four patients exhibited asymptomatic arterial stenosis postoperatively; all had a good outcome. Kalani et al[9] reported 17 patients who underwent surgical treatment, 12 of whom presented with SAH. Fifteen patients were treated with clipping, and three with clips plus wrapping. There were four intraoperative ruptures and two postoperative SAHs, which were treated by stenting. Excellent recovery was achieved in all cases. Mooney et al[20] presented good results after treating 4 patients with direct clipping of

ACCEPTED MANUSCRIPT basilar BAs. They stated that direct clipping can obliterate basilar BAs with excellent long-term outcomes and acceptable risks[20]. Bypass surgery may be an adequate option, but carries a higher morbidity[15,18]. Baskaya et al[3] treated four patients with SAH due to BA of the ICA. Three of these patients were

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treated with an endovascular procedure; following the vasospasm period, definitive treatment with EC-IC bypass followed by trapping of the aneurysmal parent vessel was performed. Two of the patients who were treated endovascularly suffered rebleeding prior to bypass and

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trapping. Three of the four patients had a good outcome (modified Rankin Scale Score 1 or 2), whereas one patient, who suffered two episodes of rebreeding, died.

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Park et al[23] used an endovascular approach to treat seven patients with ICA BAs who presented with SAH. The authors performed 12 procedures, including seven endosaccular coil embolizations (four conventional, two stent-assisted, and one balloon-assisted procedure) in four patients and five endovascular ICA trapping procedures in five patients. All four patients

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treated by endosaccular coil embolization showed aneurysmal regrowth, which neither stents nor balloons could prevented. The final outcome was considered good.

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Endovascular options have revolutionized the approach to BA management. Initial descriptions of conventional coil and stent treatment still reported limited outcomes, with

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higher rates of rebleeding[19,20,21,22,23,24,25]. However, flow diverter stent (FDS) technology has had a significant impact on results. Consoli et al5treated two patients with the Pipeline device; both an excellent clinical (modified Rankin Scale, mRS 0) and angiographic outcome, and in both cases, the aneurysms were completely excluded at 6-month follow-up. Chalouhi et al4 treated eight patients harboring eight BAs. Placement of the Pipeline devices was successful in all patients. There were no procedural or perioperative complications. At the latest follow-up, all eight patients had achieved a favorable outcome (mRS 0-2). Follow-up angiography showed 100% aneurysm occlusion in five patients and marked decrease in aneurysm size in one patient.

ACCEPTED MANUSCRIPT Aydin et al2 treated 11 patients with the SILK device. All procedures were successful, and no acute complications developed in any case. Control angiographies performed 3 and 6 months post-stenting revealed complete occlusion of the aneurysms in all of the remaining nine patients (82%). Overall, 10 of the 11 patients (92%) had good clinical outcomes (mRS≤2).

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Peschillo et al[25] pointed that endovascular treatment of BAs seems to be associated with reduced morbidity and mortality and to provide a better outcome compared with surgical approaches. However, further prospective studies are needed to confirm these results[25].

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Finally, a recent review by Szmuda et al[31] evaluated treatment in 311 patients. Neither surgical nor endovascular methods had an impact on clinical outcome, aneurysm regrowth, remote

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bleeding, or complication rate[31]. Aneurysm clipping was a predictor of intraoperative bleeding, and stent-assisted coiling increased the likelihood of a second treatment, conversion to another modality, and incomplete aneurysm obliteration predisposing to rebleeding[31]. Interpretation of our results

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In our sample of seven aneurysms in six patients, 100% of BAs were successfully treated (complete exclusion in 100% on follow-up angiography). Although we had a high rate of intraoperative bleeding (42.8% of aneurysms), a good outcome (mRs of 0-1) was achieved

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in all patients, with no difference related to aneurysm size and location. There was no mortality.

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Specific findings possibly associated with BAs are a higher rate of initial normal angiography and intrinsically good outcomes, perhaps more related to dissections than to a natural history of rupture. Nevertheless, this last finding may also be biased due to the age of patients with BAs, which is usually younger than that of patients presenting with ruptured aneurysms and could allow for better outcomes[32]. In our sample, we believe that good results were consequence of rapid diagnosis and surgical procedure, allied with experienced surgeons, pre operative planning of surgery, wide dissection of surgical field to allow for maximal aneurismal control (proximal and distal) and

ACCEPTED MANUSCRIPT availability of wrapping and bypass techniques if necessary. Additionally, in all possible cases, a tridimensional pre operative angiography was performed, allowing better visualization of aneurismal sac and its relation with parent vessel. Although we could not apply routinely in all presented cases, the use of indocyanine

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green (ICG) to perform intraoperative ICG angiography may be an important adjuvant tool to access technical results[6]. At last, in all cases, an endovascular team was always available in case of unsuccessful surgical treatment or need for complementary endovascular treatment.

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The pathophysiology of BAs makes them a challenging lesion to treat. Nevertheless, even with advances in flow diverter techniques, we still believe that surgical treatment can be

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largely successful, with acceptable complications, morbidity, and mortality. In short, our key message is that, although FDS have become the preferred treatment of these lesions, surgical treatment is a valuable option in experienced hands and well selected patients and there should always be capabilities in place to convert surgery into bypass if necessary. However, we must

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be aware that, even with the animating results presented in this study, surgical treatment of BAs may be quite dangerous and good results are not always common.

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An additional advantage of surgical treatment is that most BAs present with acute SAH, and stenting requires full antiaggregation therapy to prevent thrombosis. In the context of acute

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bleeding, such antiaggegation might be harmful, although some reports have considered such antiaggregation a tolerable risk. Surgical treatment may achieve similar results[17,18] without the need for antiaggregation.

Two limitations of the present report must be mentioned. Our series of seven aneurysms

in six patients was small, and the retrospective nature of our analysis precludes comparison of our results to those obtained with other treatment modalities. These limitations probably weaken but do not invalidate our findings.

ACCEPTED MANUSCRIPT Conclusions Surgical treatment of BAs may be effective and with clinical outcomes comparable to

Conflicts of interest

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Authors declare no conflicts of interest.

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those of FDS in well selected and conducted patients.

ACCEPTED MANUSCRIPT References 1. Ahn JY, Cho JH, Jung JY, Lee BH, Yoon PH (2008) Blister-like aneurysms of the supraclinoid internal carotid artery: challenging endovascular treatment with stentassisted coiling. J Clin Neurosci 15(9):1058-61.

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2. Aydin K, Arat A, Sencer S, Hakyemez B, Barburoglu M, Sencer A, İzgi N (2015) Treatment of ruptured blood blister-like aneurysms with flow diverter SILK stents. J

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Neurointerv Surg 7(3):202-9.

3. Başkaya MK, Ahmed AS, Ateş O, Niemann D (2008) Surgical treatment of

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blood blister-like aneurysms of the supraclinoid internal carotid artery with extracranialintracranial bypass and trapping. Neurosurg Focus 24(2):E13. 4. Chalouhi N, Zanaty M, Tjoumakaris S, Gonzalez LF, Hasan D, Kung D, Rosenwasser RH, Jabbour P (2014) Treatment of blister-like aneurysms with the pipeline

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embolization device. Neurosurgery 74(5):527-32; discussion 532. 5. Consoli A, Nappini S, Renieri L, Limbucci N, Ricciardi F, Mangiafico S (2012) Treatment of two blood blister-like aneurysms with flow diverter stenting. J

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Neurointerv Surg 4(3):e4.

6. Han MS, Joo SP, Jung SH, Kim TS (2015) Specific and helpful intraoperative

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indocyanine green videoangiography finding of bloodblister-like aneurysm of internal carotid artery. Acta Neurochir (Wien) 157(11):1849-54.

7. Ishikawa T, Nakamura N, Houkin K, Nomura M (1997) Pathological consideration of a "blister-like" aneurysm at the superior wall of the internal carotid artery: case report. Neurosurgery 40(2):403-5; discussion 405-6.

ACCEPTED MANUSCRIPT 8. Joo SP, Kim TS, Moon KS, Kwak HJ, Lee JK, Kim JH, Kim SH (2006) Arterial suturing followed by clip reinforcement with circumferential wrapping for blister-like aneurysms of the internal carotid artery. Surg Neurol 66(4):424-8; discussion 428-9. 9. Kalani MY, Zabramski JM, Kim LJ, Chowdhry SA, Mendes GA, Nakaji P, McDougall

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CG, Albuquerque FC, Spetzler RF (2013) Long-term follow-up of blister aneurysms of the internal carotid artery. Neurosurgery 73(6):1026-33; discussion 1033.

10. Kamijo K, Matsui T (2013) Acute extracranial-intracranial bypass using a radial artery

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graft along with trapping of a ruptured blood blister–like aneurysm of the internal

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carotid artery. Clinical article. J Neurosurg 113(4):781-5.

11. Kawashima A, Okada Y, Kawamata T, Onda H, Kubo O, Hori T (2008) Successful treatment of a blood blister-like aneurysm of the internal carotid artery by trapping with a high-flow bypass. J Clin Neurosci 15(7):797-800.

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12. Kim BM, Chung EC, Park SI, Choi CS, Won YS (2007) Treatment of blood blisterlike aneurysm of the internal carotid artery with stent-assisted coil embolization followed by stent-within-a-stent technique. Case report. J Neurosurg 107(6):1211-3.

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13. Korja M, Rautio R, Valtonen S, Haapanen A (2008) Primary treatment of ruptured blood blister-like aneurysms with stent-assisted coil embolization: report of two cases.

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Acta Radiol 49(2):180-3.

14. Lee BH, Kim BM, Park MS, Park SI, Chung EC, Suh SH, Choi CS, Won YS, Yu IK (2009) Reconstructive endovascular treatment of ruptured blood blister-like aneurysms of the internal carotid artery. J Neurosurg 110(3):431-6. 15. Lee JW, Choi HG, Jung JY, Huh SK, Lee KC (2009) Surgical strategies for ruptured blister-like aneurysms arising from the internal carotid artery: a clinical analysis of 18 consecutive patients. Acta Neurochir (Wien) 151(2):125-30.

ACCEPTED MANUSCRIPT 16. McLaughlin N, Laroche M, Bojanowski MW (2010) Surgical management of blood blister-like aneurysms of the internal carotid artery. World Neurosurg 74(45):483-93. 17. McNeely PD, Clarke DB, Baxter B, Vandorpe RA, Mendez I (2000) Endovascular

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treatment of a "blister-like" aneurysm of the internal carotid artery.Can J Neurol Sci 27(3):247-50.

18. Meling TR, Sorteberg A, Bakke SJ, Slettebø H, Hernesniemi J, Sorteberg W (2008)

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Blood blister-like aneurysms of the internal carotid artery trunk causing subarachnoid

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hemorrhage: treatment and outcome. J Neurosurg 108(4):662-71.

19. Mizutani T , Miki Y, Kojima H, Suzuki H (1999) Proposed classification of nonatherosclerotic cerebral fusiform anddissecting aneurysms. Neurosurgery 45(2):2539; discussion 259-60.

MY, Nakaji

P, Albuquerque

FC, McDougall

CG, Spetzler

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20. Mooney MA, Kalani

RF, Zabramski JM (2015) Long-term Patient Outcomes After Microsurgical Treatment of Blister-Like Aneurysms of the Basilar Artery. Neurosurgery Suppl 3:387-93.

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21. Ogawa A, Suzuki M, Ogasawara K (2000) Aneurysms at nonbranching sites in the surpaclinoid portion of the internal carotid artery: internal carotid artery trunk

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aneurysms. Neurosurgery 47(3):578-83; discussion 583-6.

22. Pahl FH, Oliveira MF, Rotta JM (2014) Natural course of subarachnoid hemorrhage is worse in elderly patients. Arq Neuropsiquiatr 72(11):862-6.

23. Park JH, Park IS, Han DH, Kim SH, Oh CW, Kim JE, Kim HJ, Han MH, Kwon OK (2007) Endovascular treatment of blood blister-like aneurysms of the internal carotid artery. J Neurosurg 106(5):812-9.

ACCEPTED MANUSCRIPT 24. Pelz

DM, Ferguson

GG, Lownie

SP, Kachur

E

(2003)

Combined

endovascular/neurosurgical therapy of blister-like distal internal carotid aneurysms.Can J Neurol Sci 30(1):49-53. 25. Peschillo S, Miscusi M, Caporlingua A, Cannizzaro D, Santoro A, Delfini R, Guidetti

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G, Missori P (2015) Blister-like Aneurysms in Atypical Locations: A Single-Center Experience and Comprehensive Literature Review. World Neurosurg 84(4):1070-9. 26. Peschillo S, Missori P, Piano M, Cannizzaro D, Guidetti G, Santoro A, Cenzato M

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(2015) Blister-like aneurysms of middle cerebral artery: a multicenter retrospective

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review of diagnosis and treatment in three patients.Neurosurg Rev 38(1):197-202; discussion 202-3.

27. Regelsberger J, Matschke J, Grzyska U, Ries T, Fiehler J, Köppen J, Westphal M (2011) Blister-like aneurysms--a diagnostic and therapeutic challenge. Neurosurg Rev

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34(4):409-16.

28. Sekula RF Jr, Cohen DB, Quigley MR, Jannetta PJ (2006) Primary treatment of a blister-like aneurysm with an encircling clip graft: technical case report. Neurosurgery

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59(1 Suppl 1):ONSE168; discussion ONSE168. 29. Sim SY, Shin YS, Cho KG, Kim SY, Kim SH, Ahn YH, Yoon SH, Cho KH (2006)

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Blood blister-like aneurysms at nonbranching sites of the internal carotid artery. J Neurosurg 105(3):400-5.

30. Sundt TM Jr, Murphey F (1969) Clip-grafts for aneurysm and small vessel surgery. 3. Clinical experience in intracranial internal carotid artery aneurysms. J Neurosurg 31:59–71.

ACCEPTED MANUSCRIPT 31. Szmuda T, Sloniewski P, Waszak PM, Springer J, Szmuda M (2015) Towards a new treatment paradigm for ruptured blood blister-like aneurysms of the internal carotid artery? A rapid systematic review. J Neurointerv Surg 19. pii: neurintsurg-2015-011665. 32. Yanaka K, Meguro K, Nose T (2002) Repair of a tear at the base of a blister-

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like aneurysm with suturing and an encircling clip: technical note. Neurosurgery

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50(1):218-21.

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Table 1. Summarized data of patients submitted to treatment of blister aneurysms.

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Figure legends

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Table 2. Details of surgery, complications, outcome and follow-up of patients.

Figure 1. Computed tomography(CT), pre operative angiogram and post operative angiogram of patient 4, disclosing Fisher III SAH and ACA blister aneurysm. Figure 2. CT of patient 5 revealing SAH, pre operative angiogram with ICA aneurysm and post operative angiogram. Figure 3. Above, CT of patient 1 revealing SAH and pre operative angiogram with basilar aneurysm. Below, presigmoid approach for aneurismal clipping and post operative angiogram.

ACCEPTED MANUSCRIPT Patient Age

Gende r

SAH Number of aneurysms

Size (mm)

Site

Fisher Hunt Hess

46

F

+

1

3

B

2

2

2

33

F

+

1

3

ICA

3

2

3

57

M

+

1

7

ICA

4

2

4

64

M

+

1

3

ACA

3

3

5

44

M

+

2

2/4

ICA

2

2

6

58

F

+

1

6

ICA

3

3

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1

ACCEPTED MANUSCRIPT Arterial stenosis

mRs at discharge

Follow up (years)

Complete

-

0

9

-

Complete

+

1

1

-

-

Complete

-

0

7

Clip + stent

+

+

Complete

+

1

3

ICA

Clip

-

-

Complete

-

0

1

ICA

Clip

-

-

0

2

Intraoperative bleeding

First Negative Occlusion angiograph y

1

B

Clip

+

-

2

ICA

Clip

+

3

ICA

Clip

4

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5 6

+

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Procedure

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Site

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Patien t

Complete

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ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT

Hospital do Servidor Público Estadual de São Paulo

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HIGHLIGHTS

1. Blister like aneurysms are challenging due to high risk of bleeding and difficult

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clip reconstruction. Surgery and endovascular strategies may be tried.

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2. In a consecutive series, we describe positive results of surgical approach.

Best regards,

Dr. Matheus Fernandes de Oliveira

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Hospital do Servidor Público Estadual de São Paulo

ACCEPTED MANUSCRIPT Abbreviations

BA – blister like aneurysm SAH – subarachnoid hemorrhage

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mRs – modified Rankin Score ICA – Internal carotid artery ACA – anterior cerebral artery

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B – basilar artery diverter stent

ACCEPTED MANUSCRIPT DISCLOSURE

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The authors declare no conflicts of interest!

Blister-Like Aneurysms: Report of Successful Surgical Treatment of Consecutive Cases and Review of the Literature.

Blister-like aneurysms (BAs) are usually defined as arterial lesions arising from nonbranching sites on intracranial arteries. Because of specific pec...
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