- Email: [email protected]
When the Clips Do Not Fit
News items of interest may be forwarded to: Felipe C. Albuquerque, M.D. Section Editor, WORLD Neurosurgery News E-mail: [email protected]
National Cancer Institute of Canada Clinical Trials Group: Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987-996, 2005.
Felipe C. Albuquerque, M.D.
Issam Awad, M.D.
Section Editor, WORLD Neurosurgery News
Section Editor, WORLD Neurosurgery News
4. Wang R, Chadalavada K, Wilshire J, Kowalik U, Hovinga KE, Geber A, Fligelman B, Leversha M, Brennan C, Tabar V: Glioblastoma stem-like cells give rise to tumour endothelium. Nature 468:829-833, 2010.
1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved. DOI: 10.1016/j.wneu.2011.02.038
When the Clips Do Not Fit George M. Ghobrial, Aaron S. Dumont, Pascal M. Jabbour
OBJECTIVE Giant aneurysms (⬎2.5 cm) carry up to a 40% risk of rupture in the anterior circulation at five years, according to the International Study of Unruptured Intracranial Aneurysms, and therefore necessitate early surgical intervention (13). Clip ligation has been the preferred method of treatment because of the high recurrence rate of giant aneurysms treated via endovascular surgery (2). We present a case of an elective clip ligation of a middle cerebral artery (MCA) giant aneurysm that required fenestration of the bone flap during the closure to make room for the large clips, with placement of a titanium mesh cap on top of the fenestration to protect the clips from the friction with the skin flap.
flap. A burr hole was placed in the center of the bone flap to allow room for the clips, and a titanium mesh enclosure (Styker, Kalamazoo, MI) was then placed on top of the fenestration of the bone flap to protect the clips from any pressure exerted by the skin flap (Figure 4). Then, the bone was put back with miniplates and screws and a small titanium cap above the clips (Figure 5).
Figure 1. Cerebral angiogram (lateral view). A 2.6 by 2.4-cm giant, right MCA-bifurcation aneurysm is shown.
CLINICAL PRESENTATION A 45-year-old woman underwent an elective craniotomy for clip ligation of a giant right MCA aneurysm diagnosed on a headache workup (Figure 1).
INTERVENTION AND TECHNIQUE The patient had a pterional craniotomy. Once the aneurysm was exposed, suction decompression technique was used to deflate the aneurysm and further identify both M2 branches. The aneurysm was then clipped and the parent vessel was reconstructed with two Mizuho magnetic resonance imaging-compatible (Mizuho America Inc., Union City, CA) 30-mm clips and two Mizuho magnetic resonance imagingcompatible 35-mm clips and two 40-mm clips (Figure 2). Intraoperative cerebral angiography demonstrated adequate clipping of the aneurysm. The dura was then closed around the clips (Figure 3). However, the clips were too long to allow for a tension-free closure of the bone
WORLD NEUROSURGERY 75 [3/4]: 338-343, MARCH/APRIL 2011
DISCUSSION Giant aneurysms carry the risk of up to 50% in five years of rupture according to the International Study of Unruptured Intracranial Aneurysms, which necessitates early surgical intervention because complete endosaccular occlusion of unruptured giant aneurysms is not feasible with coiling alone (3, 5, 13). Coiling of aneurysms greater than 2 cm has been noted to carry a high likelihood of coil compaction or recurrence (3). In
Figure 2. Intraoperative photograph (magnified). Multiple, parallel long aneurysm clips projecting out of the Sylvian fissure.
www.WORLDNEUROSURGERY.org
339
WORLD NEUROSURGERY NEWS
aneurysms larger than 1 cm, Rooij and Sluzewski (8) reported a rate of 64% for recurrence or coil compaction. Experience has shown that the treatment with clipping versus coiling of giant aneurysms is on a case-bycase basis (1, 3, 9, 11, 12). For giant aneurysms, the location, presence, or absence of collateral circulation, intraluminal thrombus, and calcifiFigure 3. Intraoperative photograph. A cation of the luminal wall are durotomy is made to accommodate more likely to be encountered the clips. than in smaller aneurysms, increasing the complexity (1). In addition, giant aneurysms carry the consideration for their size and the safe placement of large clips. In one series from 1979 of 80 patients, Sundt and Piepgras (11) noted a combined morbidity and mortality of 8%. In a study of 62 giant aneurysms clipped by a pterional approach from 1998 to 2006, Hauck et al. (4) noted complete occlusion in 90%, also with a morbidity and mortality of 8%. Thrombosis, calcification, and the presence of a wide neck can make treatment difficult. The use of booster clips, compression clips (4, 6, 10), and the so-called “multiple-clipping” technique allows for obliteration of the aneurysm in a controlled manner, as performed here by the senior author. Application of multiple clips can be used to obtain both an optimum closing pressure as well as to decrease the likelihood of undesirable reconfiguration of the parent
REFERENCES 1. Cantore G, Santoro A, Guidetti G, Delfinis CP, Colonnese C, Passacantilli E: Surgical treatment of giant intracranial aneurysms: current viewpoint. Neurosurgery 63:279-287, 2008. 2. Hanel RA, Spetzler RF: Surgical treatment of complex aneurysms. Neurosurgery 62:1289-1299, 2008. 3. Hauck EF, Wohlfeld B, Guai Welch B, White JA, Samson D: Clipping of very large or giant unruptured intracranial aneurysm in the anterior circulation: an outcome study. J Neurosurg 109:1012-1018, 2008. 4. Hosobuchi Y: Direct surgical treatment of giant intracranial aneurysms. J Neurosurg 51:743-756, 1979. 5. Li MH, Li YD, Fang C, Gu BX, Cheng YS, Wang YL, Gao BL, Zhao JG, Wang J, Li M: Endovascular treatment of giant or very large intracranial aneurysms
340
www.SCIENCEDIRECT.com
artery (6, 7, 9). Tanaka et al. (12) have shown in their case series of giant aneurysms that kinking of the parent vessels can occur, placing the patient at an increased risk of stroke. Occlusion of the neck of the giant aneurysm is by far the most effective approach to treatment. However, in one series of 40 by Hosobuchi (4), that was only initially achieved in seven of these patients.
Figure 4. Intraoperative photograph. The cranial flap is fenestrated and the hole covered with a titanium mesh enclosure.
CONCLUSION Ultra-long clips (⬎30 mm) are usually used in the treatment of giant aneurysms. In this case, a cranioplasty was performed to accommodate the full length of the clips, without disrupting the configuration of the clips, providing a cosmetic closure, as well as preventing torque on the clips and as a direct result, limiting manipulation of the parent vessel.
with different modalities: an analysis of 20 cases. Neuroradiology 49:819-828, 2007. 6. Nussbaum ES, Nussbaum LA: A Novel aneurysm clip design for atheromatous, thrombotic, or previously coiled lesions: preliminary experience with the “compression clip” in 6 cases. Neurosurgery 67:ons333-341, 2010. 7. Origitano TC, Schwartz K, Anderson D, Azar-Kia B, Reichman OH: Operative clip application and intraoperative angiography for intracranial aneurysms. Surg Neurol 51:117-128, 1999. 8. Rooij WJ, Sluzewski M: Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms. Am J Neuroradiol 27:16781680, 2006. 9. Sano H: Treatment of complex intracranial aneurysms of anterior circulation using multiple clips. Acta Neurochir Suppl 107:27-31, 2010. 10. Sugita K, Kobayashi S, Inoue T, Takemae T: Characteristics and use of ultra-long aneurysm clips. J Neurosurg 60:145-150, 1984.
Figure 5. Intraoperative photograph. With the bone in place, the titanium mesh will protect the long clips from pressure from the skin flap.
11. Sundt TM Jr, Piepgras DG: Surgical approach to giant intracranial aneurysms: operative experience with 80 cases. J Neurosurg 51:731-742, 1979. 12. Tanaka Y, Kobayashi S, Kyoshima K, Sugita K: Multiple clipping technique for large and giant internal carotid artery aneurysm and complications: angiographic analysis. J Neurosurg 80:635-642, 1994. 13. Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O’Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC; International Study of Unruptured Intracranial Aneurysms Investigators: Unruptured intracranial aneurysms: natural History, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103110, 2003.
1878-8750/$ - see front matter © 2011 Published by Elsevier Inc. DOI: 10.1016/j.wneu.2011.02.039
75 [3/4]: 338-343, MARCH/APRIL 2011 WORLD NEUROSURGERY
National Cancer Institute of Canada Clinical Trials Group: Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med 352:987-996, 2005.
Felipe C. Albuquerque, M.D.
Issam Awad, M.D.
Section Editor, WORLD Neurosurgery News
Section Editor, WORLD Neurosurgery News
4. Wang R, Chadalavada K, Wilshire J, Kowalik U, Hovinga KE, Geber A, Fligelman B, Leversha M, Brennan C, Tabar V: Glioblastoma stem-like cells give rise to tumour endothelium. Nature 468:829-833, 2010.
1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved. DOI: 10.1016/j.wneu.2011.02.038
When the Clips Do Not Fit George M. Ghobrial, Aaron S. Dumont, Pascal M. Jabbour
OBJECTIVE Giant aneurysms (⬎2.5 cm) carry up to a 40% risk of rupture in the anterior circulation at five years, according to the International Study of Unruptured Intracranial Aneurysms, and therefore necessitate early surgical intervention (13). Clip ligation has been the preferred method of treatment because of the high recurrence rate of giant aneurysms treated via endovascular surgery (2). We present a case of an elective clip ligation of a middle cerebral artery (MCA) giant aneurysm that required fenestration of the bone flap during the closure to make room for the large clips, with placement of a titanium mesh cap on top of the fenestration to protect the clips from the friction with the skin flap.
flap. A burr hole was placed in the center of the bone flap to allow room for the clips, and a titanium mesh enclosure (Styker, Kalamazoo, MI) was then placed on top of the fenestration of the bone flap to protect the clips from any pressure exerted by the skin flap (Figure 4). Then, the bone was put back with miniplates and screws and a small titanium cap above the clips (Figure 5).
Figure 1. Cerebral angiogram (lateral view). A 2.6 by 2.4-cm giant, right MCA-bifurcation aneurysm is shown.
CLINICAL PRESENTATION A 45-year-old woman underwent an elective craniotomy for clip ligation of a giant right MCA aneurysm diagnosed on a headache workup (Figure 1).
INTERVENTION AND TECHNIQUE The patient had a pterional craniotomy. Once the aneurysm was exposed, suction decompression technique was used to deflate the aneurysm and further identify both M2 branches. The aneurysm was then clipped and the parent vessel was reconstructed with two Mizuho magnetic resonance imaging-compatible (Mizuho America Inc., Union City, CA) 30-mm clips and two Mizuho magnetic resonance imagingcompatible 35-mm clips and two 40-mm clips (Figure 2). Intraoperative cerebral angiography demonstrated adequate clipping of the aneurysm. The dura was then closed around the clips (Figure 3). However, the clips were too long to allow for a tension-free closure of the bone
WORLD NEUROSURGERY 75 [3/4]: 338-343, MARCH/APRIL 2011
DISCUSSION Giant aneurysms carry the risk of up to 50% in five years of rupture according to the International Study of Unruptured Intracranial Aneurysms, which necessitates early surgical intervention because complete endosaccular occlusion of unruptured giant aneurysms is not feasible with coiling alone (3, 5, 13). Coiling of aneurysms greater than 2 cm has been noted to carry a high likelihood of coil compaction or recurrence (3). In
Figure 2. Intraoperative photograph (magnified). Multiple, parallel long aneurysm clips projecting out of the Sylvian fissure.
www.WORLDNEUROSURGERY.org
339
WORLD NEUROSURGERY NEWS
aneurysms larger than 1 cm, Rooij and Sluzewski (8) reported a rate of 64% for recurrence or coil compaction. Experience has shown that the treatment with clipping versus coiling of giant aneurysms is on a case-bycase basis (1, 3, 9, 11, 12). For giant aneurysms, the location, presence, or absence of collateral circulation, intraluminal thrombus, and calcifiFigure 3. Intraoperative photograph. A cation of the luminal wall are durotomy is made to accommodate more likely to be encountered the clips. than in smaller aneurysms, increasing the complexity (1). In addition, giant aneurysms carry the consideration for their size and the safe placement of large clips. In one series from 1979 of 80 patients, Sundt and Piepgras (11) noted a combined morbidity and mortality of 8%. In a study of 62 giant aneurysms clipped by a pterional approach from 1998 to 2006, Hauck et al. (4) noted complete occlusion in 90%, also with a morbidity and mortality of 8%. Thrombosis, calcification, and the presence of a wide neck can make treatment difficult. The use of booster clips, compression clips (4, 6, 10), and the so-called “multiple-clipping” technique allows for obliteration of the aneurysm in a controlled manner, as performed here by the senior author. Application of multiple clips can be used to obtain both an optimum closing pressure as well as to decrease the likelihood of undesirable reconfiguration of the parent
REFERENCES 1. Cantore G, Santoro A, Guidetti G, Delfinis CP, Colonnese C, Passacantilli E: Surgical treatment of giant intracranial aneurysms: current viewpoint. Neurosurgery 63:279-287, 2008. 2. Hanel RA, Spetzler RF: Surgical treatment of complex aneurysms. Neurosurgery 62:1289-1299, 2008. 3. Hauck EF, Wohlfeld B, Guai Welch B, White JA, Samson D: Clipping of very large or giant unruptured intracranial aneurysm in the anterior circulation: an outcome study. J Neurosurg 109:1012-1018, 2008. 4. Hosobuchi Y: Direct surgical treatment of giant intracranial aneurysms. J Neurosurg 51:743-756, 1979. 5. Li MH, Li YD, Fang C, Gu BX, Cheng YS, Wang YL, Gao BL, Zhao JG, Wang J, Li M: Endovascular treatment of giant or very large intracranial aneurysms
340
www.SCIENCEDIRECT.com
artery (6, 7, 9). Tanaka et al. (12) have shown in their case series of giant aneurysms that kinking of the parent vessels can occur, placing the patient at an increased risk of stroke. Occlusion of the neck of the giant aneurysm is by far the most effective approach to treatment. However, in one series of 40 by Hosobuchi (4), that was only initially achieved in seven of these patients.
Figure 4. Intraoperative photograph. The cranial flap is fenestrated and the hole covered with a titanium mesh enclosure.
CONCLUSION Ultra-long clips (⬎30 mm) are usually used in the treatment of giant aneurysms. In this case, a cranioplasty was performed to accommodate the full length of the clips, without disrupting the configuration of the clips, providing a cosmetic closure, as well as preventing torque on the clips and as a direct result, limiting manipulation of the parent vessel.
with different modalities: an analysis of 20 cases. Neuroradiology 49:819-828, 2007. 6. Nussbaum ES, Nussbaum LA: A Novel aneurysm clip design for atheromatous, thrombotic, or previously coiled lesions: preliminary experience with the “compression clip” in 6 cases. Neurosurgery 67:ons333-341, 2010. 7. Origitano TC, Schwartz K, Anderson D, Azar-Kia B, Reichman OH: Operative clip application and intraoperative angiography for intracranial aneurysms. Surg Neurol 51:117-128, 1999. 8. Rooij WJ, Sluzewski M: Procedural morbidity and mortality of elective coil treatment of unruptured intracranial aneurysms. Am J Neuroradiol 27:16781680, 2006. 9. Sano H: Treatment of complex intracranial aneurysms of anterior circulation using multiple clips. Acta Neurochir Suppl 107:27-31, 2010. 10. Sugita K, Kobayashi S, Inoue T, Takemae T: Characteristics and use of ultra-long aneurysm clips. J Neurosurg 60:145-150, 1984.
Figure 5. Intraoperative photograph. With the bone in place, the titanium mesh will protect the long clips from pressure from the skin flap.
11. Sundt TM Jr, Piepgras DG: Surgical approach to giant intracranial aneurysms: operative experience with 80 cases. J Neurosurg 51:731-742, 1979. 12. Tanaka Y, Kobayashi S, Kyoshima K, Sugita K: Multiple clipping technique for large and giant internal carotid artery aneurysm and complications: angiographic analysis. J Neurosurg 80:635-642, 1994. 13. Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O’Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC; International Study of Unruptured Intracranial Aneurysms Investigators: Unruptured intracranial aneurysms: natural History, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103110, 2003.
1878-8750/$ - see front matter © 2011 Published by Elsevier Inc. DOI: 10.1016/j.wneu.2011.02.039
75 [3/4]: 338-343, MARCH/APRIL 2011 WORLD NEUROSURGERY