Direct Clipping of a Thrombosed Giant Cerebral Aneurysm After Thrombectomy Without Bleeding to Minimize the Temporary Occlusion Time -Technical Case Report-

Abstract

A 75-year-old man was referred to our hospital with a thrombosed giant middle cerebral artery aneurysm manifesting as progressive memory disturbance and disorientation. Magnetic resonance imaging and conventional angiography revealed a partially thrombosed giant aneurysm of the left middle cerebral artery bifurcation and edema of the adjacent brain which had enlarged compared to 3 months before. Surgery was performed through a left frontotemporal craniotomy. After exposure of the aneurysm neck, we tried to apply a clip, which slipped due to the intraaneurysmal thrombus. Intraoperative motor evoked potential monitoring showed decreased amplitude. Therefore, the aneurysm dome was incised and the intraaneurysmal thrombus near the neck was shaved with the ultrasonic aspirator, followed by neck clipping of the aneurysm. The residual thrombus was safely removed. Transient right hemiparesis was observed after surgery, but his memory disturbance gradually improved. Giant thrombosed aneurysm can be treated by reduction of the thrombus from the far side to the lumen to reduce the duration of parent artery occlusion required for clipping.

Unexpected Rupture of a Giant Lobulated Thrombotic Middle Cerebral Artery Aneurysm and Emergency Surgical Treatment With Thrombectomy: A Case Report and Review of the Literature

“…An enormous intra-aneurysmal thrombus poses an obstacle against closing the aneurysm from the outside. Thrombectomy prevents the large mass effect of the thrombus and increases the visibility of the aneurysmal neck ( 3 ). With this attempt, it is also possible to avoid occlusion of the parent artery and the distal MCA, and it is ensured that the vascular anatomy is kept under control ( 3 , 10 ).…”

“…Thrombectomy prevents the large mass effect of the thrombus and increases the visibility of the aneurysmal neck ( 3 ). With this attempt, it is also possible to avoid occlusion of the parent artery and the distal MCA, and it is ensured that the vascular anatomy is kept under control ( 3 , 10 ). Yet, in the case presented, the aneurysmal morphology impeded the protection of the parent artery and its branches.…”

“…A lobular aneurysmal structure is reported very rarely, and only for the ninth time with this case report. Surgical treatment of a giant intracranial aneurysm can be very difficult and is not always successful ( 3 ). Several factors may complicate the treatment, including restricted visibility of surrounding vascular and neural structures due to the magnitude of the aneurysm, a widened and calcified aneurysmal neck, a thrombus within the aneurysm, and mass effect with proximity to the cranial nerves and vital neural structures.…”

“…Several factors may complicate the treatment, including restricted visibility of surrounding vascular and neural structures due to the magnitude of the aneurysm, a widened and calcified aneurysmal neck, a thrombus within the aneurysm, and mass effect with proximity to the cranial nerves and vital neural structures. For these reasons, treatment of giant intracranial aneurysms is one of the most challenging cerebrovascular problems in neurosurgery ( 3 , 4 ).…”

The combined treatment of stenting and surgery in a giant unruptured aneurysm of the middle cerebral artery

“…[ 12 41 ] They are characterized by intraluminal thrombi, mural calcifications, fusiform aspect, incorporation of M1 tract-M2 branches into the base or dome becoming consequently challenging for either surgical clipping or coiling alone. [ 41 ] Due to the anatomical variability of such aneurysms, several surgical strategies have been performed for these complex cases, as aneurysm thrombectomy with clip reconstruction,[ 16 41 45 50 ] aneurysm exicision with an in situ bypass,[ 31 40 41 ] Hunterian proximal MCA occlusion[ 6 10 14 41 50 ] and surgical trapping[ 7 10 14 37 41 50 ] both with or without cerebral rivascularization. Many vascular neurosurgeons actually prefer safe alternatives to surgery, as endovascular parent artery sacrifice with possible surgical extracranial–intracranial bypass.…”