• Pritam Gurung, Yasushi Motoyama, Ichiro Nakagawa, Hun Soo Park, Yasuo Hironaka, Young Su Park, Hideyuki Ohnishi, and Hiroyuki Nakase.
• Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Hyogo, Japan.
• World Neurosurg. 2016 Dec 1; 96: 280-284.

BackgroundBlood blister aneurysms (BBAs) of the internal carotid artery (ICA) are challenging vascular lesions for neurosurgeons because they are fragile and difficult to clip. They are commonly found at the dorsal wall of the ICA. Trapping is an alternative for these lesions, accompanied by vascular reconstruction. However, they are sometimes close to the posterior communicating artery and anterior choroidal artery.Case DescriptionA 30-year-old man presented with subarachnoid hemorrhage caused by rupture of a BBA in the right distal ICA. After construction of a high-flow bypass, the BBA was accessed via the standard pterional approach to end only in proximal clipping. Two weeks later, the remnant of the BBA showed a tendency to grow. Therefore, the anterior temporal approach was successfully used to obliterate the BBA using an oblique clip technique under direct inspection of patency of the perforators.ConclusionsThe anterior temporal approach to a BBA in the distal ICA is amenable to application of the oblique clip technique, which can provide direct inspection of the perforators emanating from the posteromedial wall of the ICA as well as obliteration of the pathologic wall. Furthermore, less retraction of the frontal lobe is also reasonable for avoidance of premature rupture of a fragile BBA.Copyright © 2016 Elsevier Inc. All rights reserved.

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