Salvage Bypass for Intraoperative Rupture of a Blood Blister-Like Aneurysm of the Internal Carotid Artery: 2-Dimensional Operative Video

Blood blister-like aneurysms (BBAs) are challenging to treat because of the high rupture risk.(1,2)The fragility of the BBA wall requires a contingency surgical plan to be established in anticipation of intraprocedural rupture.(3,4)Direct clipping during intraoperative rupture is suboptimal because there is no distinguishable neck and previously proposed techniques such as cotton clip or cotton sling entail rerupture or regrowth risks.(5-8)Trapping and bypass are robust rescuestrategies for intraoperative rupture. Both immediately exclude the bleeding point and provide flow replacement and ischemia protection, which are vital in high-grade subarachnoid hemorrhage cases.(9-11)We present a case of a 41-year-old man with a preoperative diagnosis of a ruptured left posterior communicating artery aneurysm, later revealed as aventral internal carotid artery wall BBA. Other treatment options were discussed including endovascular interventionsand clipping.(1,12)After thorough consideration with our multidisciplinary team, open surgery was decided for thispatient.(13,14)This ventral wall BBA was reruptured during exposure. We illustrate the management of intraoperative BBArupture and rescue strategy through a combination of a superficial temporal artery to middle cerebral artery (MCA)bypass and high-flow cervical internal carotid artery to M2 MCA bypass as a salvage treatment for intraoperative ruptureof BBA. We demonstrate the use of MCA arterial pressure monitoring through superficial temporal artery to MCA bypassto confirm adequateflow provided by the high-flow bypass. After intensive physical rehabilitation, the patient recoveredto a modified Rankin score of 3. The patient and his family consented to the procedure and publication of images