Download Clip Reconstruction of a Recurrent Anterior Communicating Artery Aneurysm
Clip Reconstruction of a Recurrent Anterior Communicating Artery Aneurysm
Aneurysm recurrence after microsurgical clipping is rare and may require reoperation. However, scar tissue, obscured anatomy, and obstructive clips make clipping difficult. Clip removal may clarify th...
Aneurysm recurrence after microsurgical clipping is rare and may require reoperation. However, scar tissue, obscured anatomy, and obstructive clips make clipping difficult. Clip removal may clarify the anatomy, but increases the risk of intraoperative rupture. This case demonstrates these problems and their management. A 59 year-old man with an anterior communicating artery (ACoA) aneurysm that was clipped 10 years ago presented in coma from subarachnoid hemorrhage. Angiography demonstrated a broad-based ACoA aneurysm recurrence with 4 clips placed from both right and left sides through bilateral craniotomies. Aneurysm anatomy was unfavorable for coiling. The right pterional craniotomy was re-opened, and a bifrontal craniotomy was performed in case distal anterior cerebral arteries (ACA) required revascularization. The aneurysm was exposed subfrontally and efferent A2 segments were densely scarred. The previous clips impeded neck clipping and were removed under temporary occlusion of both A1 ACA segments. Adherence of the last clip to the aneurysm wall precipitated rupture as it was removed. The ACoA neck was reconstructed with two fenestrated clips and a curved clip to close the neck remaining within the fenestration. Postoperative angiography confirmed complete exclusion of the aneurysm. The patient made a good recovery was discharged to rehabilitation. Unavoidable scar tissue, previous clips, and increased likelihood of intraoperative rupture with clip removal complicate recurrent aneurysms after bilateral clipping. Cautious dissection of arterial landmarks, liberal use of temporary clips, and removal of obstructive clips facilitate clipping. Although not used in this case, intraoperative angiography may be valuable in clipping recurrent aneurysms.Show more
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