Internal Carotid Aneurysm with Circumferential Dilatation

Summary:Clipping an aneurysmal neck is considered an optimal treatment modality for ruptured and unruptured cerebral aneurysms. However, various anatomical variations in the relationships of parent artery, branched arteries, shape of the aneurysmal dome and aneurysmal neck frequently make it difficult to apply a simple clipping method using a single clip. To achieve safe and effective neck clipping, we use several techniques such as the clipping on wrapping method (COW method), tentative parallel clipping method (TPC method) and combination clipping with fenestrated clips (CCFC method). In this study, we analyzed the safety and effectiveness of these methods. In 515 surgeries for cerebral aneurysm performed between January 2001 and December 2003, the COW method, TPC method and CCFC method were used in 61 cases, 11 cases and 26 cases, respectively. In patients treated by the COW method, slight stenosis of the parent arteries was found on longterm follow-up studies in only 2 patients. In patients treated by the TPC method and/or CCFC method, complete obliteration of the aneurysm and preservation of blood flow through the parent arteries and branched arteries were confirmed. These 3 techniques are safe and effective methods for aneurysmal neck clipping.

Techniques and Methods for Safe and Effective Clipping of Aneurysmal Neck

Nishi¹,

Koga²,

Yamashiro³

et al. 2007

Ruptured Blister-like Aneurysm Originating from the Anterior Wall of the Internal Carotid Artery: Counterplans for Pitfalls in Diagnosis and Treatment

Fujioka¹,

Nishi²,

Koga³

et al. 2008

Summary:The ruptured blister-like aneurysm originating from the anterior wall of the internal carotid artery (BLA) was known to have several pitfalls in diagnosis and treatment. Because of their unusual size and shape, BLAs are apt to be overlooked in the initial conventional examination.Furthermore, BLAs with fragile walls can rupture easily during microsurgery and cause postoperative fatal rebleeding more frequently than other aneurysms. We retrospectively reviewed 8 patients with BLA seen at our institution during the past 8 years to discuss couterplans for pitfalls in diagnosis and treatment. Seven of 8 patients were women between the age of 28 and 62 years (mean 48.6 years). BLAs were localized in the right side in 6 patients. In 4 patients, multiple angiographies were required to confirm the diagnosis because of lack of awareness of these lesions. We believe the key point to avoid misdiagnosis is to focus on the anterior wall of the internal carotid artery using several 3-dimensional images such as 3D-CTA. We treated all the BLAs with the so-called clipping on wrapping method (CWM). All patients except the first 1, who died of postoperative rebleeding due to incomplete obliteration of the neck, achieved favorable clinical outcomes. We describe the detailed procedure of CWM, which we modified to prevent poor clinical outcomes.

Treatment of Nonbranching Site Aneurysm Arise from the Internal Carotid Artery System

Wakabayashi¹,

Kurosaki²,

Kouga³

et al. 2009

Summary:We experienced 5 cases of nonbranching site aneurysms arising from the internal carotid artery system in the past 5 years. Two cases were successfully treated with neck clipping and 2 cases were treated with trapping. Wrapping by gauze and fibrin glue was used in 1 unruptured case.The outcome was good in all cases (mRS 0-2).However, non-branching site aneurysms have fragile walls, the neck is not clearly defined and postoperative rebleeding can easily occur. We believe the sacrifice of a normal parent artery is necessary to prevent re-bleeding. For this reason, we believe interception of the parent artery should always be considered to prevent postoperative rebleeding.When parent artery interception is of concern regarding postoperative ischemic events, a high-flow EC-IC bypass may be needed. On the other hand, the issue of separation of the neck is possible at all sides and the possibility of clipping strangling part of the parent artery also exists.