✓ Between 1975 and 1992, 2211 patients underwent aneurysmal neck clipping at the Nara Medical University clinic and associated hospitals. The aneurysm in 931 of these patients was situated at the junction of the internal carotid artery (ICA) and posterior communicating artery (PCoA). Seven patients were readmitted 4 to 17 years after the first surgery because of regrowth and rupture of an ICA-PCoA aneurysmal sac that had arisen from the residual neck. On angiograms obtained following aneurysmal neck clipping, a large primitive type of PCoA was demonstrated in six patients and a small PCoA in one. A small residual aneurysm was confirmed in only two patients and angiographically complete neck clipping in five. Recurrent ICA-PCoA aneurysms were separated into two types based on the position of the old clip in relation to the new growth. Type 1 aneurysms regrow from the entire neck and balloon eccentrically. In this type, it is possible to apply the clip at the neck as in conventional clipping for a ruptured aneurysm. Type 2 includes aneurysms in which the proximal portion of a previous clip is situated at the corner of the ICA and aneurysmal neck and the distal portion on the enlarged dome of the aneurysm, because the sac is regrowing from a portion of the residual neck. In this type of aneurysm, a Sugita fenestrated clip can occlude the residual neck, overriding the old clip. Classifying these aneurysms into two groups is very useful from a surgical point of view because it is possible to apply a new clip without removing the old clip, which was found to be adherent to surrounding tissue.
Although multiple cerebral aneurysms ae well recognized, a new aneurysm has only rarely been documented after successful treatment for an aneurysm elsewhere. In our consecutive series of 986 patients with intracranial saccular arterial aneurysm collected from 1975 to 1990, nine patients who had previously unverified (hence, de novo) intracranial aneurysms and ruptures at intervals of 4 to 7.5 years after clipping of an initial aneurysm are presented here. All nine had undergone successful treatment of a previous aneurysm; preoperative and postoperative angiography showed not only successful clipping of the first aneurysm but also no incidence of multiple aneurysms. These patients had suffered from hypertension before their second admission. Seven of the nine patients were treated surgically. All patients had experienced angiographical or symptomatic vasospasm after the first subarachnoid hemorrhage. In the second admission however, seven patients who underwent the surgery for a new aneurysm suffered from no vasospasm in spite of the prominent second subarachnoid hemorrhage. Two of the nine patients died of primary brain damage due to the hemorrhage and underwent necropsy. A histological study of a new aneurysm demonstrated the same findings as that of a usual saccular aneurysm. This clinical study of our patients suggests that it is important to control blood pressure for protection against a new aneurysm formation.
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