A technique for sequential, progressive clipping for a giant thrombosed distal anterior cerebral artery aneurysm: Technical note

Abstract

Background:Giant thrombosed aneurysms often present with thickened walls and a hard thrombus, including in the near-neck aneurysmal sac. These usually make it difficult to achieve complete neck clipping with preservation of local branch patency. Here, we demonstrate a simple but safe and effective technique to overcome these problems in a patient with a 6-cm giant thrombosed distal anterior cerebral artery aneurysm.Case Description:A 77-year-old-man suffered from loss of volitional activity due to the frontal mass effect. The aneurysm was exposed with unilateral paramedian craniotomy and an interhemispheric approach. The clip was applied to the aneurysmal neck but it slipped onto the parent artery, which caused branch artery occlusion. Intra-aneurysmal thrombectomy was immediately performed near the aneurysmal neck with ultrasonic aspiration. The next clip was added along the aneurysm side of the preceding clip, which was then removed. This procedure was repeated twice so that complete neck clipping was achieved while preserving the branch patency. All the residual thrombus and aneurysmal wall were subsequently removed. Postoperatively, there was no additional neurological deficit. The patient's mental function was significantly improved.Conclusions:We conclude that the sequential, progressive clipping technique is a robust option for successful neck clipping of giant thrombosed aneurysms.

A giant A4-A5 distal anterior cerebral artery aneurysm treated with microsurgical clip reconstruction

“…The majority of DACA aneurysms (69-82%) are located within the A3 segment, usually around the callosomarginal-pericallosal junction. DACA aneurysms of the A4-A5 segments are rare, representing 5-20% of DACA aneurysms, and less than 0.6% of all intracranial aneurysms (7,10,13,16,17,19,21,23,29,30,31). A4-A5 aneurysms arise anywhere along the horizontal portion of the ACA back towards the spleneum of the corpus callosum, and the distal cortical branches that arise from the termination of that segment (12).…”

“…The distal anterior cerebral artery (DACA) represents all segments of the anterior cerebral artery (ACA) distal to the anterior communicating artery. DACA aneurysms constitute up to 6% of all intracranial aneurysms (7,10,12,13,16,17,19,21,23,29,30,31).…”

Superficial Temporal Artery Extended Interposition Graft to Anterior Cerebral Artery Bypass for the Treatment of a Large Fusiform Distal Anterior Cerebral Artery Aneurysm: 2-Dimensional Operative Video

“…Clip reconstruction and sequential progressive clipping have been described in the management of giant thrombosed DACA aneurysms. 1,2 Customized revascularization with bypass, side-toside anastomosis, and trapping of the aneurysmal segment have also been performed for treating DACA aneurysms. [3][4][5][6][7][8][9][10][11][12] We present a 2-dimensional operative video of superficial temporal artery (STA) to distal anterior cerebral artery bypass, followed by trapping of the aneurysm-bearing segment.…”