Use of the Sundt Clip Graft in a Previously Coiled Internal Carotid Artery Blister-Like Aneurysm

Abstract

Owing to the focal wall defect covered with thin fibrous tissues, an aneurysm arising from the dorsal wall of the internal carotid artery (ICA) is difficult to manage either surgically or endovascularly and is often associated with high morbidity and mortality. Unfortunately, the definitive treatment modality of such highly risky aneurysm has not yet been demonstrated. Upon encountering the complex intracranial pathophysiology of such a highly precarious aneurysm, a neurosurgeon would be faced with a challenge to decide on an optimal approach. This is a case of multiple paraclinoid aneurysms including the ICA dorsal wall aneurysm, presented with spontaneous subarachnoid hemorrhage. With respect to treatment, direct clipping with a Sundt graft clip was performed after multiple endovascular interventions had failed. This surgical approach can be a treatment modality for a blood blister-like aneurysm after failed endovascular intervention(s).

Nonsaccular aneurysms: A wide comparison between the four main types

“…Intracranial fusiform aneurysms are rare, although the number of cases has increased in recent years, mainly in young patients. [413162029] They represent about 3–13% of all intracranial aneurysms and they are often presented at the vertebrobasilar system. [2024] Fusiform aneurysms in the anterior circulation are less frequent when compared with the posterior circulation and most of the times, the middle cerebral artery (MCA) is the most affected, followed by the internal carotid artery (ICA) and the anterior cerebral artery (ACA).…”

“…The patient can present symptoms and signs of occlusion, arterial rupture, or mass effect. [42024] Fusiform aneurysms present more often with ischemic stroke or mass effect. [27]…”

“…On account of its lower rates of treatment-related morbidity as well as their efficacy, EVTs have emerged as the treatment of choice. [41031] However, a number of endovascular approaches to the treatment of VBDA exist. The EVT can be reconstructive, like stent placement, flow diversion (FD), and stent-assisted coiling or deconstructive techniques such as parent artery occlusion and trapping of the aneurysm.…”

The Blood Blister Like-aneurysm: Usefulness of Sundt Clip

“…Cho et al 2) and Cho et al 3) reported separately the modified application of Sundt clip, which was placed over the stented or stent-associated coiled artery before Sundt clip operation. Besides, in case 5 and 20, there showed the other possibility of reinforcement of Sundt clip by Yasargil clip or bam sheet.…”

“…This kind of dorsal wall aneurysm have been challenged by many neurosurgeons with various modalities (conventional clip, clip with wrapping, using Sundt [encircling] clip, trapping, and stent assisted coil, etc). 2) 5) 7) 9) 10) 11) 16) 17) 18) Although the advancement in microneurosurgery and endovascular techniques have been archived, the optimal treatment of BBA remained controversy. The dorsal wall aneurysm comprise 0.9–6.5% of all ICA aneurysm, 12) furthermore BBA comprise much smaller percentage of all ICA aneurysm.…”