Microsurgical Clipping of Eight Intracranial Aneurysms in a Patient
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.304102
Source of Support: None, Conflict of Interest: None
A 54-year-old female patient presented with acute SAH (Hunt and Hess grade I) with blood predominantly in left sylvian fissure. DSA revealed eight (Left: A1-paraclinoid, A2-ophthalmic segment, A3-anterior choroidal, A4-ICA bifurcation, A5-M1 segment, and A6-MCA bifurcation aneurysms. Right: A7-Ophthalmic segment and A8-MCA bifurcation aneurysms) small (<10 mm) intracranial intradural aneurysms. From CT and DSA findings, the ruptured aneurysm was probably left MCA bifurcation aneurysm. All eight intradural aneurysms (A1-A8) were planned for clipping in two sessions. Left pterional craniotomy and clipping of 6 aneurysms on left side was done on first day. Initially left paraclinoidal (A1), ophthalmic segment (A2), anterior choroidal (A3), ICA bifurcation (A4) aneurysms were clipped after applying bulldog clamp on cervical ICA. Later M1 segment (A5) and MCA bifurcation (A6) aneurysms were clipped with temp clip on left M1 [Figure 1] and [Video 1]. The sequence of clipping these multiple aneurysms was from proximal to distal aneurysms (A1 to A4 with temp bull-dog clamp on left cervical ICA followed by A5 and A6 with temp clip on left M1) despite distal aneurysm (A6- left MCA bifurcation aneurysm) being the ruptured one. This sequence was followed to avoid placement of temporary clips only distal to an unsecured proximal aneurysm. Patient recovered completely (GCS-E4V5M6) from first surgery and had no neurological deficits. Right ptrerional craniotomy and clipping of the right ophthalmic segment aneurysm (A7) followed by right MCA bifurcation aneurysm was done next day. Eleven aneurysm clips were used for clipping these 8 aneurysms. Postoperative course was uneventful. Check angiogram (DSA) done before discharge revealed small residual left paraclinoid aneurysm (4.6 Õ 4.2 Õ 3 mm) and successful clip ligation of the remaining 7 aneurysms [Figure 1] and [Figure 2]. Residual aneurysm (A1) was extending proximally beyond the level of the origin of left ophthalmic artery and probably extending to the clinoid segment (C5) of ICA [Figure 1]g. Successful stent assisted coiling (1 stent, 3 coils) of the residual paraclinoid aneurysm was done after three months. Obscured visualization due to overlapping images of multiple clips [Figure 1]h near the area of interest was a major challenge in getting satisfactory working projection during coiling of the residual aneurysm. At a follow-up of 16 months after surgery, patient was asymptomatic with no neurological deficits.
MIAs is a high risk condition requiring prompt and early treatment of both ruptured and unruptured (silent) aneurysms. In patients with MIAs, risk of bleeding as high as 10–17% from silent aneurysms is reported., Though ruptured aneurysm in patients with MIAs can be determined with CT and cerebral angiogram in majority of cases, it might be difficult to identify the ruptured aneurysm in few patients. Considering the risk of bleeding from even small silent aneurysms and difficulty in precisely identifying the ruptured aneurysm in a few patients with MIAs, our Institute policy is to secure all the MIAs as early as possible depending on the patient condition and location of MIAs. MIAs can be managed either surgically or by endovascular techniques. In developing countries, clipping is a cost effective treatment compared to coiling. Device cost of coils and stent used for coiling residual aneurysm was more than the clips used for clipping 8 aneurysms in the present case reflecting the cost effectiveness of clipping for MIAs in developing countries like India. Good results comparable to endovascular treatment can be achieved with microsurgery for MIAs and as many as 8 intracranial aneurysms in one patient can be safely clipped.
A = Aneurysm
CT = Computed tomography
DSA = Digital subtraction angiogram
GCS = Glasgow coma scale
ICA = Internal carotid artery
MCA = Middle cerebral artery
MIAs = Multiple intracranial aneurysms
SAH = Sub arachnoid hemorrhage
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]