Acute extracranial-intracranial bypass using a radial artery graft along with trapping of a ruptured blood blister–like aneurysm of the internal carotid artery

Clinical article

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Fragile aneurysm walls and poorly defined necks render the surgical treatment of blood blister–like aneurysms (BBAs) located at nonbranching sites of the supraclinoid internal carotid artery extremely challenging. Such aneurysms have a remarkable tendency to rupture during surgery, especially during the acute period. The authors describe the clinical course of patients with subarachnoid hemorrhage (SAH) caused by BBA rupture and emphasize the value of internal carotid artery trapping combined with high-flow extracranial-intracranial (trapping/EC-IC) bypass during the acute period following SAH.


The authors analyzed the clinical records of 7 consecutive female patients with a mean age of 61 years (range 51–77 years) who had been treated between January 2006 and December 2008 at their institute.


All 7 patients presented with SAHs corresponding to Fisher Grade 3 and World Federation of Neurosurgical Societies Grades II, III, IV, and V in 3, 1, 2, and 1 patient, respectively. Surgery was postponed in the 3 patients, including 1 in whom the trapping/EC-IC bypass procedure was performed during the chronic period. Two of the 3 patients in whom surgery was postponed experienced preoperative rebleeding, and repeated angiography revealed remarkable enlargement of the aneurysm; both of these patients died before surgery could be performed. The remaining 4 patients underwent trapping/EC-IC bypass during the acute period following SAH. The outcome was excellent (Glasgow Outcome Scale Scores 5), and postoperative angiography demonstrated complete obliteration of the BBA as well as good graft patency in all 5 patients who underwent trapping/EC-IC bypass. Intraoperative bleeding from the BBAs never occurred in any of these 5 patients.


Ruptured BBAs were successfully treated with a trapping/EC-IC bypass during the acute SAH period. This surgical strategy for treating BBAs during the acute period might be a promising option for these rare but high-risk lesions.

Abbreviations used in this paper: BBA = blood blister–like aneurysm; DS = digital subtraction; EC-IC = extracranial-intracranial; GOS = Glasgow Outcome Scale; ICA = internal carotid artery; RA = radial artery; SAH = subarachnoid hemorrhage; SWS = stent-within-a-stent; trapping/EC-IC bypass = trapping of the ICA aneurysm combined with high-flow EC-IC bypass; WFNS = World Federation of Neurosurgical Societies.

Article Information

Address correspondence to: Koji Kamijo, M.D., Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan. email:

Please include this information when citing this paper: published online November 20, 2009; DOI: 10.3171/2009.10.JNS09970.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Case 5. Anteroposterior DS angiogram showing an aneurysm measuring 5 × 3 mm (arrow) at nonbranching sites in the supraclinoid portion of the left ICA.

  • View in gallery

    Case 5. Intraoperative photograph depicting the blood blister–like bulge (arrow) and purplish discoloration (arrowheads) of the left ICA. A clip is located just distal to the aneurysm.

  • View in gallery

    Case 5. Postoperative anteroposterior DS angiogram demonstrating obliteration of the aneurysm and patency of the bypass graft. The left middle cerebral artery is under severe vasospasm (arrows) after trapping/EC-IC bypass.


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