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Coiling of the post-clipping recurrent aneurysm. (A) Brain CT scan illustrating subarachnoid hemorrhage at the suprasellar cistern; a metallic artefact can be seen. (B) Brain CTA illustrating the recurrent anterior communicating aneurysm; the clip can be seen (white arrow). (C) DSA of the left internal carotid artery illustrating the moyamoya-like vessels in the region of middle cerebral artery. (D) Three-dimensional DSA illustrating the recurrent anterior communicating aneurysm and the clip (white arrow). (E) Unsubtracted and (F) subtracted angiogram illustrating that the aneurysm is coiled completely. For the case presented in the image, the first clipping was performed five years ago. CT, computed tomography; CTA, computed tomography angiography; DSA, digital subtraction angiography; L, left; R, right.
Source publication
Following the clipping of intracranial aneurysms, post-clipping residual or recurrent aneurysms (PCRRAs) can occur. In recent years, the incidence of PCRRAs has increased due to a prolonged follow-up period and advanced imaging techniques. However, several aspects of intracranial PCRRAs remain unclear. Therefore, the present study performed an in-d...
Context in source publication
Context 1
... coiling is the most practical method to treat an intracranial PCRRA, particularly for PCRRAs with a narrow neck (Fig. 3). Gross et al (59) used single coiling in 18 cases of narrow-neck PCRRAs and observed no recurrence during an average follow-up period of 3.9 years. However, in wide-necked, large, complex PCRRAs, stent-or balloon-assisted EVT is required (61,64,65). The recanalization rate is high in complex PCRRAs ...
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Citations
Salvage treatment of postclipping recurrent aneurysms remains challenging. 1,2 The salvage microsurgical clipping is a possible intervention but sometimes difficult because of tissue adhesions around the aneurysm and previously installed clips; therefore, salvage coil embolization may have certain advantages. ¹⁻⁵ However, when coil embolization is not applicable, ⁶ microsurgical clipping is a stand-alone curative treatment, requiring proficient and reliable microsurgical techniques. This article describes a unique case of a 70-year-old female patient complaining of a severe headache with subarachnoid hemorrhage due to a recurrent ruptured left internal carotid-posterior communicating artery aneurysm after microsurgical clipping 23 years ago. An initial attempt at coil embolization proved unsuccessful because of the aneurysm shape. Consequently, the salvage microsurgical clipping was planned. Given the additional time for trapping the internal carotid artery for the old clip removal, a superficial temporal artery-middle cerebral artery bypass was also planned. The operation entailed a superficial temporal artery-middle cerebral artery bypass, a Sylvian fissure dissection, the old clip removal, and aneurysm clipping. Intraoperatively, the complete aneurysm neck clipping was successfully performed without any complication, and patient postoperative course was uneventful. A wide surgical field should be obtained to be able to manipulate the aneurysm and old clip safely under a microscope. It is also important to temporarily trap the main artery to ensure removal of old clips and to prepare for intraprocedural ischemia using bypass after a precise assessment of hemodynamics before surgery. The patient provided informed consent for the procedure and the publication of the case along with its pertinent imaging, and this report was approved by the institutional review board at our hospital.
