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How I do it: surgical clip reconstruction of a large, partially thrombosed, ruptured middle cerebral artery aneurysm

  • How I Do it - Vascular Neurosurgery - Aneurysm
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Abstract

Background

Ruptured large and partially thrombosed aneurysms are challenging lesions to treat successfully.

Methods

We describe the surgical treatment of a large, ruptured partially thrombosed middle cerebral artery (MCA) aneurysm. Once the Sylvian fissure is dissected, temporary clips are placed, and the clot is evacuated with simple microsuction and ultrasonic aspiration. The aneurysm is then carefully clip reconstructed to avoid compromise of the parent vessels.

Conclusion

In cases of surgical clipping of large, thrombosed aneurysms, it is important to be aware of a few, but critically important, pitfalls to ensure successful outcome.

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References

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Author information

Authors and Affiliations

  1. Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA

    Lorenzo Rinaldo, Thomas J. Sorenson & Leonardo Rangel Castilla

  2. Department of Radiology, Mayo Clinic, Rochester, MN, USA

    Lorenzo Rinaldo & Leonardo Rangel Castilla

  3. School of Medicine, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55414, USA

    Thomas J. Sorenson

  4. Department of Neurologic Surgery, University of Padua, Padua, Italy

    Enrico Giordan

Authors
  1. Lorenzo Rinaldo
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  2. Thomas J. Sorenson
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  3. Enrico Giordan
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  4. Leonardo Rangel Castilla
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Corresponding author

Correspondence to Thomas J. Sorenson.

Additional information

Summary of key points

• A frontotemporal craniotomy over the “keyhole” should be utilized and the extradural lesser sphenoid wing drilled down to facilitate wide opening of the Sylvian fissure.

• Decompression of the thrombotic aneurysm sac with microsuction and microscissors is performed until active bleeding is encountered.

• The soft thrombus can be removed with microsuction, and gentle ultrasonic aspiration should be utilized for the atheromatous parts of the clot.

• Meticulous removal of atheroma from the aneurysm wall and ostium is imperative to prevent delayed thromboembolism.

• Often in complex aneurysms, we prefer a system of multiple tandem clips (often using a fenestrated straight clip as the first one) as opposed to a single clip.

• A small neck remnant should be left to prevent the post-clipping kinking off of parent vessels.

• Post-clip reconstruction patency of the parent vessels and obliteration of the aneurysm is recommended to be confirmed with intraoperative Doppler ultrasonography and/or ICG fluorescein angiography.

• We recommend prophylactically preparing the STA for a possible bypass situation and have a low threshold for its use.

• Postoperative angiography is indicated to confirm patency of parent vessels and occlusion of aneurysm.

• Emphasis should be placed on the data indicating surgical treatment when counseling patients about surgical and endovascular options.

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This article is part of the Topical Collection on Vascular Neurosurgery - Aneurysm.

Electronic supplementary material

Microsurgical management of a giant, partially thrombosed middle cerebral artery aneurysm with clip reconstruction in a 48-year-old man with hypertension, who presented with acute subarachnoid hemorrhage. (MP4 89.9 mb)

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Rinaldo, L., Sorenson, T.J., Giordan, E. et al. How I do it: surgical clip reconstruction of a large, partially thrombosed, ruptured middle cerebral artery aneurysm. Acta Neurochir 162, 911–915 (2020). https://doi.org/10.1007/s00701-020-04252-6

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  • DOI: https://doi.org/10.1007/s00701-020-04252-6

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