Combined microsurgical and endovascular approach in the hybrid operating angiosuite: A case series on blood-blister intracranial aneurysms

Purpose: Blood blister-like aneurysms (BBAs) are small, fragile vascular lesions that develop on the walls of the supraclinoid internal carotid artery. This absence of a neck complicates surgical and endovascular treatment options. The hybrid operating angiosuite (HOA), which integrates traditional surgical techniques with endovascular interventions, provides an innovative approach to managing BBAs. This study aims to evaluate a series of clinical cases focused on treating BBAs using a combination of microsurgical extracranial-intracranial bypass and endovascular trapping within the HOA. Methods: We analyzed a series of patients with BBAs treated from 2014 to 2022. Skilled bimanual neurovascular surgeons implemented treatment plans using both microsurgical and neurointerventional techniques across four distinguished neurosurgery centers: Kangdong Sacred Heart Hospital, Seoul St. Mary’s Hospital, Yongin Severance Hospital, and International St. Mary’s Hospital. Clinical outcomes were measured using the Glasgow Outcome Scale (GOS) at discharge and the modified Rankin Score (mRS) during follow-up, with scores of 0–2 indicating favorable outcomes. Follow-up imaging via computed tomography angiography or magnetic resonance angiography was conducted on average 6–12 months post-procedure to assess BBA recurrence and graft vessel patency. Results: Seven patients (average age, 45 years) were treated at the HOA. The surgical approach included high-flow bypass in five patients and superficial temporal artery double-barrel bypass in two. Follow-up imaging revealed no BBA recurrences and maintained patency of bypass flow. Conclusion: Our findings suggest that a hybrid approach offers a safer and more effective strategy for managing BBAs, potentially improving patient outcomes.