Elsevier

World Neurosurgery

Volume 110, February 2018, Pages e605-e611
World Neurosurgery

Original Article
Surgical Outcome of Very Small Intracranial Aneurysms Utilizing the Double Clip Technique

https://doi.org/10.1016/j.wneu.2017.11.060Get rights and content

Objectives

To report the outcome of patients with very small intracranial aneurysm (VSIA) undergoing surgical clipping using a double-clip technique.

Methods

This cross-sectional study was conducted in Namazi Hospital, the main referral neurovascular center in Southern Iran during a 6-year period from September 2010 to March 2016. All patients with VSIAs (≤3 mm) undergoing surgery with double-clip technique were included. This technique reduces the clip slippage. The short- and long-term outcomes determined by Glasgow outcome score (GOS), modified Rankin Scale (MRS), and complications.

Results

Operations were performed on 32 VSIAs in 26 patients with a mean ± SD age of 55.7 ± 10.1 years. Middle cerebral artery was the most common location for VSIA (50.0%). There was no neck remnant, and the complete occlusion rate was 100%. The rate of intraoperative aneurysm rupture was 30.8%, and none of the patients experienced rebleeding. The 6-month mortality rate was 0% in ruptured VSIAs and 6.25% in unruptured VSIAs. Most of the patients had favorable outcomes (88.5%), and the overall mortality rate was 11.5%. The rate of permanent neurologic deficit was 10.0% in ruptured and 12.5% in unruptured VSIAs. Multivariate logistic regression analysis revealed no association between baseline and clinical characteristics and outcome in this series.

Conclusion

VSIAs are difficult to treat because of their small sizes; therefore, with a double-clip technique, one can reduce complications related to the treatment of small aneurysms.

Introduction

Very small intracranial aneurysms (VSIAs), defined as intracranial aneurysms measuring 3 mm or less,1, 2 are rare, and their management remains a dilemma for neurosurgeons.3 As the natural course and life-time risk of bleeding in unruptured VSIAs is not fully understood, there is controversy regarding their management.4, 5 Most of the authors believe that microsurgery is an acceptable option for treatment of ruptured VSIAs, because coiling of these aneurysms is technically demanding and is associated with higher complication rates compared with larger aneurysms.6 The surgical outcomes for VSIAs (both ruptured and unruptured) have been excellent with low mortality and morbidity rates.1, 7, 8, 9

Surgical management of VSIAs requires special considerations to minimize the complications and morbidity rates. These aneurysms should be clipped with mini-clips, which have a smaller closing force than the standard aneurysm clips.7, 10 Surgeon and operating room experience are among the most important factors determining the outcome in surgical management of patients with VSIAs.1, 2, 7, 8 Recently, a Helsinki team7 presented a novel technique in which two mini-clips are applied parallel to each other for obliterating the VSIAs (double-clip technique), and now there is a desire to check study this methodology in different environment. The aim of the current study was to report the feasibility and safety of the double-clip technique for microsurgical management of VSIAs in a large referral center in southern Iran.

Section snippets

Study Population

This cross-sectional study was conducted during a 6-year period from September 2010 to March 2016 in Namazi Hospital, a tertiary healthcare center affiliated with Shiraz University of Medical Sciences. This center is the main referral center for neurovascular diseases in southern Iran with a high volume of patients and operations (both open and endovascular); it is well equipped and has good resources.11, 12 We included all the patients with VSIAs (≤3 mm) who underwent operations in our center

Results

We included 26 patients with 32 VSIAs who underwent operations in our center with the double-clip technique. The mean age of the patients was 55.7 ± 10.1 years (range, 28–74 years), and there were 17 (65.4%) women and 9 (34.6%) men among the patients. Total number of 32 VSIAs were diagnosed in these 26 patients. Sixteen (61.5%) patients had ruptured aneurysms, and 10 patients (38.5%) had unruptured ones. Hypertension was the most common comorbidity (50.0%), followed by ischemic heart disease

Discussion

VSIAs are a dilemma for neurovascular surgeons because their management remains controversial.1, 4, 16 Some trials have found that neurosurgical clipping is superior to endovascular coiling in patients with ruptured VSIAs2, 7, 17, 18; however, recent evidence suggests that these two are equal and in some parameters, endovascular coiling is superior to surgical clipping.19, 20, 21, 22 In the current study, we reported the outcomes for 26 patients with 32 VSIAs in our referral center in southern

Conclusion

The double-clip technique is a safe and effective technique for clipping of VSIAs (both ruptured and unruptured), and it is associated with low mortality and morbidity. The technique requires dexterity and can be learned and applied through practice and repetition.

Acknowledgments

We would like to acknowledge the assistance of Mr. Houshang Ghoje Beig, Ms. Mozhdeh Ranjbar, Ms. Fatemeh Zare, and the operating room and anesthesiology technicians at Namazi Hospital who participated in all the operations. We would also like to acknowledge the editorial assistant of the Diba Negar Research Institute for improving the manuscript.

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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.

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