Abstract
The common curative treatment of the intracranial aneurysm is neck clipping. When neck clipping is impossible or incomplete, wrapping or coating is added. But these additional treatments cannot avoid the risk of recurrence or rebleeding. Three cases are reported here, the aneurysms of which ruptured simultaneously with clipping resulting in incomplete clipping, and hemostasis was achieved by coating the aneurysms under systemic hypotension.
Case 1: A 60-year-old femele was admitted to the Department of Neurosurgery, Hiroshima University School of Medicine with a ruptured right internal carotid posterior communicating artery (ICPC) aneurysm. The operation was performed on day 0. In spite of several trials, it was difficult to clip the neck completely because of the anatomical location of the aneurysm. Finally the aneurysm was clipped but it ruptured simultaneously. With the use of a temporary clip proximal to the aneursmal neck, an additional clip was applied to the aneurysm under systemic hypotension, but incomplete clipping was apparent because bleeding continued. As bleeding gradually stopped, the temporary clip was removed, then the aneurysm was coated with Biobond Oxycel. Her postoperative course was uneventful, and she recovered fully. Neither angiograms taken on day 9 nor 27 months after the surgery showed the aneurysm.
Case 2: A 48-year-old female was admitted to the Department of Neurosurgery, Hiroshima University School of Medicine with a ruptured anterior communicating artery aneurysm. The operation was done on day 1. Though the aneurysm was clipped once, it ruptured during the confirmation of the situation of clipping. The bleeding point was the neck of the aneurysm, so another clip was applied to the neck. But bleeding continued, which showed that the neck clipping was incomplete. It was possible to stop bleeding by coating the aneurysm with Biobond Bern sheets under systemic hypotension. The aneurysm disappeared angiographically on day 9. A V-P shunt was added for normal pressure hydrocephalus (NPH) one month after the initial surgery and the patient recovered fully.
Case 3: A 60-year-old female was admitted to Department of Neurosurgery, Hiroshima University School of Medicine with a ruptured left ICPC aneurysm. The operation was performed on day 1. But only incomplete clipping was possible because of anatomical difficulty of clipping. Bleeding from the aneurysm occurred simultaneously with clipping. But is was easy to stop the bleeding by coating the aneurysm with Biobond Oxycel under systemic hypotension. Though a V-P shunt was needed for NPH, the patient recovered fully. The aneurysm could not be found angiographically either on day 9 or 6 months after the initial surgery.
A few theories have been proposed to explain the disappearance of an incompletely clipped aneurysm. Those are thrombosis of the aneurysm, occlusion of the aneurysm by the intimal thickening at the clipped site and the reinforcement of the aneurysmal wall by the granulation surrounding the aneurysm. In the three cases described above, it was additionally suggested that the aneurysm was pressed and collapsed by the coating materials.
