Objectives: Blood blister-like aneurysms (BBAs) were considered a great therapeutic challenge with high morbidity and mortality. A variety of microsurgical techniques to treat BBAs had been proposed, but few had investigated the optimal surgical approach toward the exposure of BBAs. In this study, we aimed to compare the advantages and disadvantages of Dolenc and pterional approach in the microsurgery of BBAs. Patients and methods: We retrospectively reviewed medical and surgical records of ICA (internal carotid artery) blister-like aneurysms that had been treated by microsurgery at our hospital during 2012 to 2017 and compared postoperative complications and outcomes between Dolenc and pterional approach. Results: Seventeen BBAs of 16 patients with complete information were identified from our database based on intraoperative findings. All 17 BBAs were treated with direct clipping successfully with no death or re-bleeding occurred. Six patients were performed with Dolenc approach and 10 with pterional approach. No significant difference was found regarding the incidence of intraoperative rupture (42.9% vs 0.0%, P = 0.051) or postoperative complications (ocular complications:33.3% vs 0.0%, P = 0.125; ischemic events: 33.3% vs 10.0%, P = 0.518) between the two groups. Conclusion: Dolenc approach and pterional approach were both applicable craniotomies for supraclinoid BBAs of ICA. Dolenc approach provided more exposure of ICA trunk, which ensured reliable proximal control but might also bring higher risk of oculomotor paralysis. Choice of approach should be based on the location of BBA and the available form of proximal control. (C) 2018 Elsevier Ltd. All rights reserved.