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| LETTER TO EDITOR |
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| Year : 2020 | Volume
: 68
| Issue : 6 | Page : 1481-1483 |
Microsurgical Clipping of Eight Intracranial Aneurysms in a Patient
Narayanam Anantha Sai Kiran1, Vinay Hegde2, Vivek Raj1, Alangar S Hegde1
1 Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, Karnataka, India
2 Department of Neuroradiology, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru, Karnataka, India
| Date of Web Publication | 19-Dec-2020 |
Correspondence Address:
Dr. Vivek Raj
Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bengaluru - 560 066, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.304102
How to cite this article:
Kiran NA, Hegde V, Raj V, Hegde AS. Microsurgical Clipping of Eight Intracranial Aneurysms in a Patient. Neurol India 2020;68:1481-3 |
Sir,
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. | Figure 1: Left ICA. (a-d) DSA images showing left paraclinoid (A1), ophthalmic segment (A2), anteriorchoroidal (A3), ICA bifurcation (A4), M1 segment (A5) and MCA bifurcation (A6) aneurysms. e.g.: Post operative DSA images (e AP, f Lateral) of left ICA showing successful clip ligation of all the 6 aneurysms on left side except for small residual (R- Arrow in f and g) left paraclinoid (A1) aneurysm. (h) Fluoro image during coiling showing overlapping images of multiple clips making it difficult to have satisfactory working projection. (i and j) DSA images showing successful coiling of the residual aneurysm
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 | Figure 2: Right ICA. (a-c) DSA images (A-AP, B-Lateral, C-3D reconstruction oblique) showing ophthalmic segment (A7) and MCA bifurcation (A8) aneurysms. (d-f) Post operative DSA images (d-AP, e-Lateral,f-Oblique) showing successful clip ligation of both ( A7, A8) aneurysms and normal flow in left ICA and MCA
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MIAs is a high risk condition requiring prompt and early treatment of both ruptured and unruptured (silent) aneurysms.[1] In patients with MIAs, risk of bleeding as high as 10–17% from silent aneurysms is reported.[2],[3] 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.[4] 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.[5] 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.
Abbreviation
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
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | |  |
| 1. | Vajda J. Multiple intracranial aneurysms: A high risk condition. Acta Neurochir 1992;118:59-75.  |
| 2. | Heiskanen O. Risk of bleeding from unruptured aneurysms in cases with multiple intracranial aneurysms. J Neurosurg 1981;55:524-6. |
| 3. | Inagawa T. Surgical treatment of multiple intracranial aneurysms. Acta Neurochir 1991;108:22-9. |
| 4. | Nehls DG, Flom RA, Carter LP, Spetzler RF. Multiple intracranial aneurysms: Determining the site of rupture. J Neurosurg 1985;63:342-8. |
| 5. | Zubair MT, Enam SA, Pervez RA, Bhatti A. Cost-effectiveness of clipping vs coiling of intracranial aneurysms after subarachnoid hemorrhage in a developing country--A prospective study. Surg Neurol 2009;72:355-60. |
[Figure 1], [Figure 2]
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