Advances in the treatment of intracranial blood blister-like aneurysms: a comprehensive review from surgical approaches to endovascular therapy

Intracranial blood blister-like aneurysms (BBAs) constitute a rare but clinically challenging subset of cerebrovascular lesions, distinguished by their fragile, thin-walled morphology and a tendency to arise at non-branching sites of intracranial arteries, most frequently in the supraclinoid segment of the internal carotid artery (ICA). Managing BBAs is particularly difficult due to their high propensity for rupture, rapid progression, and the challenges they pose in intraoperative identification and repair. Traditional surgical approaches, including direct clipping, wrapping, and bypass with trapping, have been employed; however, these techniques are often associated with high complication rates and technical limitations given the delicate structure of BBAs. In recent years, advances in endovascular therapy, such as stent-assisted coiling (SAC) and flow-diverter (FD) placement, have expanded the therapeutic options, offering less invasive alternatives with encouraging outcomes. Nevertheless, the optimal management strategy remains controversial, as both surgical and endovascular approaches carry distinct indications, technical challenges, and risks of recurrence or procedural complications. This narrative review systematically explores the epidemiology and pathophysiology of BBAs, delineates key diagnostic features, and critically examines both reconstructive and deconstructive treatment modalities within a stepwise, two-pathway (endovascular and surgical) algorithm, highlighting reported efficacy, complication profiles, and recommended treatment selection for distinct aneurysm subtypes. By contrasting the strengths and limitations of each approach, this article aims to provide clinicians with evidence-based guidance to support individualized management strategies for patients with BBAs.