Intentional partial coil occlusion followed by delayed clip application to wide-necked middle cerebral artery aneurysms in patients presenting with severe vasospasm

Abstract

The treatment of ruptured cerebral aneurysms in patients presenting with vasospasm remains a particular challenge. The authors treated two patients harboring Hunt and Hess Grade 1 subarachnoid hemorrhages from middle cerebral artery (MCA) aneurysms associated with severe local angiographically demonstrated yet asymptomatic vasospasm on presentation. Because both aneurysms had wide necks and were located at the MCA bifurcation, they were believed to be anatomically suitable for microsurgical clip application. Severe M, vasospasm was believed to be a relative contraindication to open surgery, however. An intentionally staged endovascular and microsurgical treatment strategy was planned in each patient. Partial coil occlusion of the aneurysmal dome was performed to prevent the lesion from rebleeding and was followed by balloon angioplasty of the spastic vessel. Early treatment of the severe spasm appeared to prevent significant delayed neurological ischemic deficit. Following resolution of the vasospasm, definitive clipping of the aneurysms was performed on Day 13 post embolization. One patient had a good clinical recovery and was discharged without neurological deficit. The other patient's hospital course was complicated by the occurrence of a postoperative posterior temporal infarct requiring partial temporal lobectomy, although she eventually had a good recovery with only a small visual field deficit. Based on data obtained in these two patients, one can infer that ruptured wide-necked MCA aneurysms associated with severe local vasospasm may best be treated using a staged combined treatment plan. Delayed clip application might be performed more safely 4 to 6 weeks postocclusion, or later, than at 2 weeks.

Stent-Assisted Coiling of Wide-Necked Aneurysms in the Setting of Acute Subarachnoid Hemorrhage

“…A thorough examination of the literature has revealed the successful treatment of these lesions by open surgical and combined open and endovascular approaches. [31][32][33][34] Undoubtedly, a significant role for open surgical intervention remains; however, the diminished operative time and minimally invasive nature of endovascular intervention have been shown to improve outcomes. This finding has been especially true in patients with higher-grade hemorrhages, multiple comorbidities, or advanced age.…”

Combined Endovascular and Microsurgical Management of Complex Cerebral Aneurysms

“…A good outcome was reported in this series that included partially coiled aneurysms, aneurysm recurrence, and/or re-rupture after coiling (41). In patients presenting with severe vasospasm, partial coiling followed by staged definitive clipping is a good algorithm to avoid microsurgical manipulation of vessels in the setting of vasospasm (42). Rabenstein et al reported a high incidence of vasospasm in SAH patients treated with clipping versus coiling (43).…”

Ruptured Aneurysm With Delayed Distal Coil Migration Requiring Surgical Treatment

“…In particular, the endovascular procedure causes fewer ischemic complications during the vasospasm phase in patients with SAH. 1,7) In this case, coil embolization was appropriate to avoid re-bleeding in the acute period.…”