Abstract
The patient, a 47-year-old man, suffered from severe subarachnoid hemorrhage on November 20, 1983. A broad-based saccular aneurysm (4×4mm) at the angle of the anterior communicating artery and left A-2, which projected to right superiorly, was revealed on the angiogram.
Two days later, neck clipping of the aneurysm was performed through the left pterional approach. Because of the high-positioned anterior communicating artery, the operative field was extremely restricted. The aneurysm neck wall looked very thin. Under mannitol administration and temporary clipping of the left A-1, a bayonet Sugita clip was placed at the neck. At that moment, a part of the neck might have been torn, and there was bleeding, but it stopped several minutes later.
Just after the operation, the patient showed an uneventful recovery, and, for the prevention of delayed vasospasm, ticlopidine chloride (300mg per day) was administered. Five days after the operation, the level of consciousness dropped to stuporous and CT revealed an increased high density area at the aneurysm site. Angiography showed a new aneurysm (2.5×8mm) at the anterior communicating artery just beside the clip.
On December 2, 1983, reoperation was performed through the same approach. A massive elastic hard clot in which the clip and bilateral A-1 to A-2 was embedded was removed meticulously piecemeal fashion using scissors. Under bilaterally placed A-1 temporary clips, the former clip was removed and a 45° angled fenestrated Sugita clip with a 5mm blade length was successfully applied on the neck of the aneurysm and the left A-2 was spared in the clip fenestration. Postoperative CT revealed a small frontal intracerebral hematoma, but the patient recovered to lead a useful life.
Although the minor tear at the neck wall of the aneurysm was considered to be the main cause of the pseudoaneurysm formation, administration of an antiplatelet agent also might act as an important promoting factor.
