The clip-wrap technique in the treatment of intracranial unclippable aneurysms

Abstract

Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. Objective: To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. Method: In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. results: The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. No early or late rebleeding was observed after 2 years mean follow-up. One patient deceased due to pulmonary tromboembolism. conclusion: Clip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. It can prevent rebleeding and represents an improvement when compared with the natural history.

Ruptured Cerebral Aneurysms: An Update

“…Although an argument for routine use of IOA exists during cerebral aneurysm surgery and substantial practice variation exists regarding use of this modality in different centers, including use of IOA routinely, selectively, or rarely. IOA should be standard in cerebral aneurysm surgery [42].Fluorescence angiography method is a microscope integrated intraoperative near-infrared indocyanine green angiography (ICG) technique and microscope-integrated light source containing infrared excitation light illuminates the operating field. ICG provides real-time information of the cerebral vasculature about aneurysms [46,48] Summarily the intraoperative monitoring and vascular imaging methods compared were complementary rather than competitive in nature method.…”

“…These aneurysms are commonly located on the middle cerebral artery, carotid ophthalmic. Clip-wrap techniques for the treatment of fusiform aneurysms seem to be safe to prevent rebleeding and represent an improvement with a low rate of acute or delayed postoperative complications [42]. In some lesions of giant or large internal carotid artery-ophthalmic artery aneurysm which cannot be trapped, proximal and distal occlusion (trapping) is the most effective strategy, however, occlusion of parent arteries has a high incidence of transient complications and may lead to ischemia [1].…”

Blister Aneurysms

“…Several authors have advocated treatment with various wrapping or combined clipping and wrapping techniques [7,21]. The vesselencircling clip graft, or Sundt clip graft, was introduced over 40 years ago, and recently, Park and Meyer described the application of Sundt clip grafts as a rescue technique when vessel dehiscence occurred perioperatively.…”

“…This selective reaction of the outer layer of the vessel wall is thought to better reinforce the aneurysm sac [27]. Several authors therefore consider cotton used without additional adhesive coating the best material for wrapping ruptured aneurysms [21,26,33].…”

Endovascular treatment of blister aneurysms

“…3), and in some cases, ICA trapping with or without bypass. 1,13,18,26,27,37,41,50 However, surgi- Given these results, the approach to treatment of blister aneurysms in recent times has shifted from open surgical treatment to endovascular treatment. This is especially the case with ongoing innovations in regard to endovascular techniques and devices.…”