Blister Aneurysms

  • James V. Byrne
  • Svein Harald Mørkve
Reference work entry


Blister aneurysms comprise about 1 % of ruptured intracranial aneurysms. They are associated with higher rates of rebleeding and, as a result, with greater mortality and morbidity than typical aneurysms. Because of rarity, the etiology and pathology are poorly understood. Diagnosis relies on a stereotypical appearance and location at non-branch points on the internal carotid artery at angiography, together with inspection at surgery. They are increasingly seen involving other intracranial arteries and generally considered to be caused by atherosclerotic mural disease.

Surgical clipping is difficult because of their small size, sessile shape, and thin sac walls. It is frequently complicated by operative rupture, and alternative wrapping and trapping are often required. For these reasons, endovascular treatments are increasingly used as an alternative. The recent introduction of high mesh density stents, designed to redirect blood flow away from aneurysms and reinforce the parent artery, has stimulated the development of new procedures to manage these lesions. Initial experiences with flow-diverting stents have shown a substantial improvement in outcomes, and stent procedures are rapidly being accepted as the intervention of choice.


Aneurysm Intracranial aneurysm Blister aneurysm Blood blister aneurysm Blister-like aneurysms Subarachnoid hemorrhage Stent Flow diverter Wrapping Clip wrapping Microsurgical clipping Endovascular therapy 


  1. 1.
    Ohara H, Sakamoto T, Suzuki J (1979) Sclerotic brain aneurysms. In: Suzuki J (ed) Cerebral aneurysms. Neuron, Tokyo, pp 673–682Google Scholar
  2. 2.
    Yasargil MG (1984) Clinical considerations, surgery of the intracranial aneurysm and results. Georg Thieme Verlag, Stuttgart/New YorkGoogle Scholar
  3. 3.
    Yoshimoto Y, Ochiai C, Nagai M (1996) Cerebral aneurysms unrelated to arterial bifurcations. Acta Neurochir (Wien) 138:958–963CrossRefGoogle Scholar
  4. 4.
    Nakagawa F, Kobayashi S, Takemae T, Sugita K (1986) Aneurysms protruding from the dorsal wall of the internal carotid artery. J Neurosurg 65:303–308CrossRefPubMedGoogle Scholar
  5. 5.
    Ishikawa T, Nakamura N, Houkin K, Nomura N (1997) Pathological consideration of a “blister-like” aneurysm at the superior wall of the internal carotid artery: case report. Neurosurgery 40:403–405CrossRefPubMedGoogle Scholar
  6. 6.
    Kim JH, Kwon TH, Kim JH, Park YK, Chung HS (2006) Internal carotid artery dorsal wall aneurysm with configurational change: are they all false aneurysms? Surg Neurol 66:441–443CrossRefPubMedGoogle Scholar
  7. 7.
    Abe M, Tabuchi K, Yokoyama H, Uchino A (1998) Blood blisterlike aneurysms of the internal carotid artery. J Neurosurg 89:419–424CrossRefPubMedGoogle Scholar
  8. 8.
    Sano K (1979) Internal carotid posterior communicating anterior choroidal region aneurysms. Microsurgical treatment. In: Pia HW, Langmaid C, Zierski J (eds) Cerebral aneurysms. Advances in diagnosis and therapy. Springer, Berlin/Heidelberg/New York, p 252Google Scholar
  9. 9.
    Ogawa A, Suzuki M, Ogasawara K (2000) Aneurysms at nonbranching sites in the supraclinoid portion of the internal carotid artery: internal carotid artery trunk aneurysms. Neurosurgery 47:578–583PubMedGoogle Scholar
  10. 10.
    Shigeta H, Kyoshima K, Nakagawa F, Kobayashi S (1992) Dorsal internal carotid artery aneurysms with special reference to angiographic presentation and surgical management. Acta Neurochir (Wien) 119:42–48CrossRefGoogle Scholar
  11. 11.
    Kinouchi H, Mizoi K, Nagamine Y, Yanagida N, Mikawa S, Suzuki A, Sasajima T, Yoshimoto T (2002) Anterior paraclinoid aneurysms. J Neurosurg 96:1000–1005CrossRefPubMedGoogle Scholar
  12. 12.
    Sim SY, Shin YS, Cho KG, Kim SY, Kim SH, Ahn YH, Yoon SH, Cho KH (2006) Blood blister-like aneurysms at nonbranching sites of the internal carotid artery. J Neurosurg 105:400–405CrossRefPubMedGoogle Scholar
  13. 13.
    Meling TR, Sorteberg A, Bakke SJ, Slettebø H, Hernesniemi J, Sorteberg W (2008) Blood blister-like aneurysms of the internal carotid artery causing subarachnoid haemorrhage: treatment and outcome. J Neurosurg 108:662–671CrossRefPubMedGoogle Scholar
  14. 14.
    Ueta T, Ichi S, Ochi T, Suzuki I (2004) Spontaneous regression of an aneurysm at a nonbranching site of the supraclinoid internal carotid artery. Case report. J Neurosurg 101:1070–1072CrossRefPubMedGoogle Scholar
  15. 15.
    Gonzalez AM, Narata AP, Yilmaz H, Bijlenga P, Radovanic I, Schaller K, Lovblad KO, Pereira VM (2014) Blood blister-like aneurysms: single center experience and systematic literature review. Eur J Radiol 83:197–205CrossRefPubMedGoogle Scholar
  16. 16.
    Meckel S, Singh TP, Undrén P, Ramgren B, Nilsson OG, Phatouros C, McAulife W, Cronqvist M (2011) Endovascular treatment using predominantly stent-assisted coil embolization and antiplatelet and anticoagulation management of ruptured blood blister-like aneurysms. AJNR Am J Neuroradiol 32:764–771CrossRefPubMedGoogle Scholar
  17. 17.
    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 106:812–819CrossRefPubMedGoogle Scholar
  18. 18.
    Garrett M, Spetzler RF (2012) Surgical treatment of blister-like aneurysms. World Neurosurg 77:76–77CrossRefPubMedGoogle Scholar
  19. 19.
    Aydin K, Arat A, Sencer S, Hakyemez B, Barburoglu M, Sencer A, Izgi N (2014) Treatment of ruptured blood blister-like aneurysms with flow diverter Silk stents. J Neurointerv Surg. doi:10.1136/neurintsurg-2013-011090PubMedGoogle Scholar
  20. 20.
    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 66:424–428CrossRefPubMedGoogle Scholar
  21. 21.
    Figueiredo EG, Foroni L, Monaco BA, Gomes MQ, Sterman Neto H, Teixeira MJ (2010) The clip-wrap technique in the treatment of unclippable aneurysms. Arq Neuropsiquiatr 68:115–118CrossRefPubMedGoogle Scholar
  22. 22.
    Park PJ, Meyer FB (2010) The Sundt clip graft. Neurosurgery 66:300–305PubMedGoogle Scholar
  23. 23.
    Cho TG, Hwang SN, Nam TK, Park SW (2012) Salvage surgical treatment for failed endovascular procedure of a blood blister-like aneurysm. J Cerebrovasc Endovasc Neurosurg 22:295–303Google Scholar
  24. 24.
    Todd NV, Tocher JL, Jones PA, Miller JD (1989) Outcome following aneurysm wrapping: a 10-year follow-up review of clipped and wrapped aneurysms. J Neurosurg 70:841–846CrossRefPubMedGoogle Scholar
  25. 25.
    Cudlip SA, Kitchen ND, McKahn GM, Bell BA (1998) Wrapping of solitary intracranial aneurysms, outcome at five years. Acta Neurochir (Wien) 140:1167–1171CrossRefGoogle Scholar
  26. 26.
    Desmukh VR, Kakarla UK, Udaya K, Figueiredo EG, Zabramski M, Spetzler R (2005) Long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms. Neurosurgery 58:434–442CrossRefGoogle Scholar
  27. 27.
    Sachs E Jr (1972) The fate of muscle and cotton wrapped about intracranial carotid artery aneurysms. A laboratory and clinico-pathological study. Acta Neurochir (Wien) 26:121–137CrossRefGoogle Scholar
  28. 28.
    Gillingham FJ (1958) The management of ruptured intracranial aneurysms. Hunterian lecture. R Coll Surg Engl 23:89–117Google Scholar
  29. 29.
    Dutton JEM (1956) Intracranial aneurysms. A new method of surgical treatment. Br J Med 2:585–586CrossRefGoogle Scholar
  30. 30.
    Cartoon CA, Kennedy JC, Heifetz MD et al (1965) The use of a plastic adhesive (methyl-2-cyanoacrylate monomer) in the management of intracranial aneurysms and leaking cerebral vessels. A report of 15 cases. In: Sahs AL, Field WS (eds) Intracranial aneurysms and subarachnoid haemorrhage. Charles C. Thomas, SpringfieldGoogle Scholar
  31. 31.
    Minakawa T, Koike T, Fujii Y, Ishii R, Tanaka R, Arai H (1987) Long term results of ruptured aneurysms treated by coating. Neurosurgery 21:660–663CrossRefPubMedGoogle Scholar
  32. 32.
    Mount LA, Antunes JL (1975) Results of treatment of intracranial aneurysms by wrapping and coating. J Neurosurg 42:189–193CrossRefPubMedGoogle Scholar
  33. 33.
    Herrera O, Kawamura S, Yasui N, Yoshida Y (2005) Histological changes in the rat common carotid artery induced by aneurysmal wrapping and coating materials. Neurol Med Chir (Tokyo) 39:134–139CrossRefGoogle Scholar
  34. 34.
    Nishioka H (1966) Report on the cooperative study of intracranial aneurysms and subarachnoid haemorrhage. Section VII. I. Evaluation of the conservative management of ruptured intracranial aneurysms. J Neurosurg 25:574–592CrossRefPubMedGoogle Scholar
  35. 35.
    Kim YB, Hong CK, Chung J, Joo JY, Huh SK (2014) Long-term clinical and angiographic outcomes of wrap- clipping strategies for unclippable cerebral aneurysms. Yonsei Med J 55:401–409PubMedCentralCrossRefPubMedGoogle Scholar
  36. 36.
    Nakano S, Iseda T, Yoneyama T, Goya T, Wakisaka S (2000) A combination of wrapping and clipping using a collagen-impregnated dacron fabric (Hemashield). Surg Neurol 53:330–333CrossRefPubMedGoogle Scholar
  37. 37.
    Kazumata K, Nakayama N, Nakamura T, Kamiyama H, Terasaka S, Houkin K (2014) Changing treatment strategy from clipping to radial artery graft bypass and parent artery sacrifice in patients with ruptured blister-like internal carotid artery aneurysms. Neurosurgery 10(Suppl 1):66–73PubMedGoogle Scholar
  38. 38.
    Murai Y, Mizunari T, Umeoka K, Tateyama K, Kobayashi S, Teramoto A (2012) Ischemic complications after radial artery grafting and aneurysmal trapping for ruptured internal carotid artery anterior wall aneurysms. World Neurosurg 77:166–171CrossRefPubMedGoogle Scholar
  39. 39.
    Schaller B (2008) Extracranial-intracranial bypass to reduce the risk of ischemic stroke in intracranial aneurysms of the anterior cerebral circulation: a systematic review. J Stroke Cerebrovasc Dis 17:287–298CrossRefPubMedGoogle Scholar
  40. 40.
    Lee BH, Kim BM, Park MS, Park SI, Cheung 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 110:431–436CrossRefPubMedGoogle Scholar
  41. 41.
    Fang YB, Li Q, Yang PF, Huang QH, Zhao WY, Xu Y, Hong B, Liu JM (2013) Treatment of blood blister-like aneurysms of the internal carotid artery with stent-assisted coil embolization. Clin Neurol Neurosurg 115:920–925CrossRefPubMedGoogle Scholar
  42. 42.
    Ihn YK, Kim SH, Sung JH, Kim TG (2012) The efficacy of endovascular treatment of ruptured blood blister-like aneurysms using stent-assisted coil embolization. Interv Neuroradiol 18:432–441PubMedCentralPubMedGoogle Scholar
  43. 43.
    Sadasivan C, Cesar L, Seong J, Rakian A, Hao Q, Tio FO, Wakhloo AK, Lieber BB (2009) An original flow diversion device for the treatment of intracranial aneurysms: evaluation in the rabbit elastase-induced model. Stroke 40:952–958PubMedCentralCrossRefPubMedGoogle Scholar
  44. 44.
    Zanaty M, Chaloui N, Tjoumakaris SI, Rosenwasser RH, Gonzalez LF, Jabbour P (2014) Flow-diversion panacea or poison? Front Neurol. doi: 10.3389/fneur.2014.00021Google Scholar
  45. 45.
    Martin AR, Cruz JP, Matouk CC, Marotta TR (2012) The pipeline flow-diverting stent for exclusion of ruptured intracranial aneurysms with difficult morphologies. Neurosurgery 70:21–28CrossRefPubMedGoogle Scholar
  46. 46.
    Chalouhi N, Zanati M, Tjoumakaris S, Gonzalez LF, Hasan D, Kung D, Rosenwasser RH, Jabbour P (2014) Treatment of blister-like aneurysms with the pipeline embolization device. Neurosurgery 74:527–532CrossRefPubMedGoogle Scholar
  47. 47.
    Rasskazoff S, Silvaggio J, Brouwer PA, Kaufmann A, Nistor A, Iancu D (2010) Endovascular treatment of a ruptured blood blister-like aneurysm with a flow-diverting stent. Interv Neuroradiol 16:255–258PubMedCentralPubMedGoogle Scholar
  48. 48.
    Wagner A, Cortsen M, Hauerberg J, Romner B, Wagner MP (2012) Treatment of intracranial aneurysms. Reconstruction of the parent artery with flow-diverting SILK-stent. Neuroradiology 54:709–718CrossRefPubMedGoogle Scholar
  49. 49.
    Cruz JP, O’Kelly C, Kelly M, Wong JH, Alshaya W, Martin A, Spears J, Marotta TR (2013) Pipeline embolization device in aneurysmal subarachnoid haemorrhage. AJNR Am J Neuroradiol 34:271–276CrossRefPubMedGoogle Scholar
  50. 50.
    Causin F, Pascarella R, Pavesi G, Marasconi R, Zambon G, Battaglia R, Munari M (2011) Acute endovascular treatment (<48 hours) of uncoilable ruptured aneurysms at non-branching sites using Silk flow-diverting devices. Interv Neuroradiol 17:357–364PubMedCentralPubMedGoogle Scholar
  51. 51.
    Nerva JD, Morton RP, Levitt MR, Osbun JW, Ferreira MJ, Ghodke BV, Kim LJ (2014) Pipeline embolization device as primary treatment for blister aneurysms and iatrogenic pseudoaneurysms of the internal carotid artery. J Neurointerv Surg. doi:10.1136/neurintsurg-2013-011047PubMedGoogle Scholar
  52. 52.
    Brinjikji W, Murad M, Lanzino G, Cloft HJ, Kallmes DF (2013) Endovascular treatment of intracranial aneurysms with flow diverters. A metaanalysis. Stroke 44:442–447CrossRefPubMedGoogle Scholar
  53. 53.
    Delgado Almandoz JE, Crandall BM, Scholz JM, Fease JL, Anderson RE, Kadkhodayan Y, Tubman DE (2013) Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline embolization device. J Neurointerv Surg 5. doi:10.1136/neurintsurg-2012-010582Google Scholar
  54. 54.
    Delgado Almandoz JE, Crandall BM, Scholz JM, Fease JL, Anderson RE, Kadkhodayan Y, Tubman DE (2014) Last-recorded P2Y12 reaction units value is strongly correlated with thromboembolic and hemorrhagic complications occurring up to 6 months after treatment in patients with cerebral aneurysms treated with the Pipeline embolization device. AJNR Am J Neuroradiol 35:128–135CrossRefPubMedGoogle Scholar
  55. 55.
    Faught RW, Satti SR, Hurst RW, Pukenas BA, Smith MJ (2014) Heterogeneous practice pattern regarding antiplatelet medications for neuroendovascular stenting in the USA: a multicenter survey. J Neurointerv Surg. doi:10.1136/neurintsurg-2013-010954Google Scholar
  56. 56.
    Pearl M, Gregg L, Gailloud P (2010) Endovascular treatment of aneurysmal subarachnoid haemorrhage. Neurosurg Clin N Am 21:271–280CrossRefPubMedGoogle Scholar
  57. 57.
    Mahaney KB, Chalouhi N, Viljoen S, Smietana J, Kung DK, Jabbour P, Bulsara KR, Howard M, Hasan DM (2013) Risk of hemorrhagic complication associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy. J Neurosurg 119:937–942CrossRefPubMedGoogle Scholar
  58. 58.
    Kung DK, Policeni BA, Capuano AW, Rossen JD, Jabbour PM, Torner JC, Howard MA, Hasan D (2011) Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling. J Neurosurg 114:1021–1027CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Nuffield Department of Surgical Sciences, Oxford UniversityJohn Radcliffe HospitalOxfordUK
  2. 2.Department of NeurosurgeryHaukeland University HospitalBergenNorway

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