Rebleeding of a neck remnant in a case of ruptured aneurysm initially treated with coils

Microsurgical Clipping of Wide-Neck Anterior Circulation Aneurysms: A Case Series From a Low- and Middle-Income Country

Background Aneurysms of the anterior circulation are the most prevalent of intracranial aneurysms, most of which are saccular. Wide-neck aneurysms (WNAs) are a specific subtype of intracranial aneurysms that are difficult to treat. Adequate endovascular management of such aneurysms requires assistive devices that are either too costly or sometimes unavailable in our setting as a resource-limited country, strongly supporting the resurgence of microsurgical clipping in the management of such understudied aneurysms. In this study, we aim to assess the short- and intermediate-term radiological and functional outcomes of microsurgical clipping in a resource-limited country. Methodology This is a case series study conducted from January 2022 to January 2024. All patients with wide neck anterior circulation aneurysms who were managed by microsurgical clipping were included in this study. Clinical, radiological, and functional outcomes were reported at 3 months and 6 months as short- and intermediate-term outcomes, respectively. Results Nine WNAs of the anterior circulation in eight patients were included. Five patients were males and three were females. AcomA was the most common location of three aneurysms. All our patients presented with ruptured aneurysms except one mirror-image M2 aneurysm. All aneurysms were completely clipped except one PcomA aneurysm that had a neck remnant that was diagnosed and managed endovascularly with a flow diverter. Six patients had favorable outcomes at discharge (modified Rankin score of 0-2). We had one case of intraoperative rupture, a single case of hydrocephalus that was treated with a ventriculoperitoneal shunt, and two cases of mortality, one of them due to delayed ischemic neurological deficit. All ruptured aneurysms were clipped using two clips. The unruptured aneurysm in the patient with two mirror-image M2 aneurysms was managed with a single clip 3 months after the ruptured one. Conclusion Microsurgical clipping continues to be a viable option in the management of WNAs both radiologically and functionally, especially in our setting as a resource-limited country where endovascular management could be costly and sometimes not available.

Long-term results of middle cerebral artery aneurysm clipping in the Barrow Ruptured Aneurysm Trial

Objective

A direct comparison of endovascular versus microsurgical treatment of ruptured middle cerebral artery (MCA) aneurysms in randomized trials is lacking. As endovascular treatment strategies continue to evolve, the number of reports of endovascular treatment of these lesions is increasing. Herein, the authors report a detailed post hoc analysis of ruptured MCA aneurysms treated by microsurgical clipping from the Barrow Ruptured Aneurysm Trial (BRAT).

Methods

The cases of patients enrolled in the BRAT who underwent microsurgical clipping for a ruptured MCA aneurysm were reviewed. Characteristics of patients and their clinical outcomes and long-term angiographic results were analyzed.

Results

Fifty patients underwent microsurgical clipping of a ruptured MCA aneurysm in the BRAT, including 21 who crossed over from the endovascular treatment arm. Four patients with nonsaccular (e.g., dissecting, fusiform, or blister) aneurysms were excluded, leaving 46 patients for analysis. Most (n = 32; 70%) patients presented with a Hunt and Hess grade II or III subarachnoid hemorrhage, with a high prevalence of intraparenchymal blood (n = 23; 50%), intraventricular blood (n = 21; 46%), or both. At the last follow-up (up to 6 years after treatment), clinical outcomes were good (modified Rankin Scale score 0–2) in 70% (n = 19) of 27 Hunt and Hess grades I–III patients and in 36% (n = 4) of 11 Hunt and Hess grade IV or V patients. There were no instances of rebleeding after the surgical clipping of aneurysms in this series at the time of last clinical follow-up.

Conclusions

Microsurgical clipping of ruptured MCA aneurysms has several advantages over endovascular treatment, including durability over time. The authors report detailed outcome data of patients with ruptured MCA aneurysms who underwent microsurgical clipping as part of a prospective, randomized trial. These results should be used for comparison with future endovascular and surgical series to ensure that the best results are being achieved for patients with ruptured MCA aneurysms.

The Medina Embolic Device: early clinical experience from a single center

Objective

To report our initial experience with the Medina Embolic Device (MED) in unruptured intracranial aneurysms either as sole treatment or in conjunction with additional devices.

Methods

15 consecutive patients (6 women, 9 men) with unruptured aneurysms were treated between September 2015 and April 2016. The aneurysm fundus measured at least 5 mm. We evaluated the angiographic appearances of treated aneurysms at the end of the procedure and at follow-up, the clinical status, complications, and requirement for adjunctive devices.

Results

The MED was successfully deployed in all but one case and adjunctive devices were required in 10 cases. Aneurysm locations were middle cerebral artery bifurcation (n=3), internal carotid artery (ICA) bifurcation (n=1), supraclinoid ICA (n=5), posterior communicating artery (n=1), anterior communicating artery (n=2), cavernous ICA (n=2), distal basilar sidewall (n=1), basilar tip (n=1). Three patients had complications although none could be attributed to the MED. Immediate angiographic results were modified Raymond-Roy classification (mRRC) I=1, mRRC II=5, mRRC IIIa=3, mRRC IIIb=5, and one patient showed contrast stasis within the fundus of the aneurysm. Follow-up angiography was available in 11 patients, with four showing complete aneurysm exclusion, six with stable remnants and one patient with an enlarging neck remnant.

Conclusions

The MED represents a major step forward in the treatment of intracranial aneurysms. It can result in rapid exclusion of an aneurysm from the circulation and has a good safety profile. We believe that the true value of the MED will be in combining its use with adjunctive devices such as endoluminal flow diverters that will result in rapid aneurysmal exclusion.