作者：王泷 蔡理 钱海 石祥恩

Key words: Blood-blister aneurysm; microsurgical suturing technique; middle cerebral artery aneurysm A 56-year-old female presented with a very severe headache and was transferred to our institution on day 7 following the onset of the episode. Multiple treatment modalities including microsurgical clipping or wrapping and endovascular coiling were not considered for this case due to the blood-blister pattern of the aneurysm (Figure 1A, 1B). After patient consent, a standard frontotemporal craniotomy was carried out. Following the Sylvian fissure split and hematoma evacuation, a blood-blister aneurysm (BBA) involving the left MCA bifurcation was exposed. The 9-0 nylon suture was utilized to obliterate the dome of the aneurysm in an interrupted fashion and was made perpendicular to the long axis of the insular segment of MCA.

The needle was passed through the normal vessel wall at a site with two times the thickness of the MCA vessel wall away from the junction between the MCA and the aneurysm (Figure 2A). The neck of the aneurysm was completely obliterated after tying the knots (Figure 2B). A total of four stitches were carried out with preservation of the normal MCA bifurcation wall (Figure 3). Complete aneurysm occlusion without MCA stenosis was confirmed by postoperative angiography, and the patient experienced uneventful outcomes (Video). This case demonstrates that the suturing technique is a viable option for BBA.

Highlights

• Surgical or endovascular treatment method for blood-blister aneurysm (BBA) remains a technical challenge.

• This video demonstrated a BBA of the middle cerebral artery that was managed by a microsurgical suturing technique.

• Complete obliteration of the aneurysm without parent vessel occlusion was observed postoperatively.

• The microsurgical suturing technique is a safe and effective method for the management of BBA.

Abbreviations list

BBA, blood-blister aneurysm;

M1, sphenoidal segment of middle cerebral artery;

M2,insular segment of the middle cerebral artery;

MCA, middle cerebral artery;