Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 1054.e1-1054.e12
World Neurosurgery

Case Report
Microneurosurgical Clip Ligation of Acutely Ruptured Cerebral Aneurysm Immediately Preceded by Intentional Subtotal Endovascular Coil Embolization Under a Single Anesthesia: Observations Using a Deliberate Combined Sequential Treatment Strategy in 13 Cases

https://doi.org/10.1016/j.wneu.2017.07.032Get rights and content
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Background

Endovascular coil embolization and craniotomy with clip ligation are the 2 most commonly used treatments for ruptured cerebral aneurysm. Although coiling maintains the advantages of brevity and complete avoidance of brain retraction and manipulation, clipping offers the benefits of decompression of the injured brain and lower rates of aneurysm recurrence. A combined, immediately sequential treatment strategy for acutely ruptured cerebral aneurysm that simultaneously maximizes the advantages of both techniques, while minimizing their respective disadvantages, may be a useful paradigm.

Objective

To demonstrate the complementarity of clipping and coiling in acutely ruptured cerebral aneurysm.

Methods

Patients with ruptured anterior circulation cerebral aneurysm standing to benefit from brain decompression were treated by a combination of coiling and microneurosurgery in rapid succession, under the same general anesthetic. Surgery consisted of clipping of the aneurysm via either craniotomy or craniectomy with expansion duraplasty in all cases, and ventriculostomy in selected cases.

Results

Coil embolization of the ruptured aneurysm was carried out rapidly and improved the efficiency of subsequent clipping by allowing early unequivocal identification of the aneurysm dome and decreased brain retraction, reducing risk of intraoperative rupture and obviating temporary occlusion. All aneurysms were shown eliminated by postoperative cerebral angiography.

Conclusions

A deliberate combined treatment strategy that uses clipping immediately preceded by subtotal coiling under a single anesthetic may be ideal for selected ruptured cerebral aneurysms, takes advantage of the unique strengths of both techniques, makes both techniques easier, and maximizes opportunity for brain protection against delayed complications in the prolonged aftermath of aneurysmal subarachnoid hemorrhage.

Key words

Aneurysm surgery
Brain protection
Cerebral aneurysm
Clipcoil strategy
Intraoperative rupture
Preemptive coil embolization
Subarachnoid hemorrhage

Abbreviations and Acronyms

AComA
Anterior communicating artery
aSAH
Aneurysmal subarachnoid hemorrhage
CT
Computed tomography
DCV
Delayed cerebral vasospasm
ICH
Intracerebral hemorrhage
mRS
modified Rankin Scale
SAH
Subarachnoid hemorrhage

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.