There are many specific aspects as for the operative intervention. the operation timing and the decision of the ruptured aneurysm for the double aneurysms. The operative procedures applied in our 42 cases of double aneurysms were as follows; direct neck clipping in 27 cases, clipping and reinforcement coating in 9 cases, coating only in 5 cases, Selverstone cervical carotid ligation in 2 cases and hematoma removal or decompression in 3 cases.
CASE #1 K.H. 24 y/o male.
Referred to our neurosurgery 4 days after the onset of paroxysmal bitemporal severe pulsating headache. Severe meningeal signs with nuchal rigidity,however, there is no neurological laterality (Hunt grade II). CSF was xanthochromic with very high pressure (not measured). Panangiography revealed an aneurysm at the anterior communicating artery which was clipped by Scoville clip via right frontotemporal craniotomy on the 6th admission day. Postoperative angiography revealed adequate clipping of the neck with minimal bowing of the anterior cerebral artery from right to left. Repeated angiography 2 weeks after the operation disclosed ANOTHER different shape aneurysms at A-1 and A-2 junction. It was confirmed as a newly formed aneurysm at the second operation. It appeared to be just distal to the Scoville clip applied in the previous operation. The second operation showed that the previous Scoville clip was not slipped off. Final angiography reveals perfect disappearance of the second aneurysm and the patient was returned to his original work on the 60th admission day.
CASE #II T.T. 48 y/o male.
Brought in to our neurosurgery on the 6th day after onset. Severe generalized headache was associated with persisting nausea and vomiting. Severe meningeal signs with nuchal rigidity and bilateral blurred discs without preretinal hemorrhage were noted on admission (Hunt grade III). Spinal tap showed xanthochromic CSF with 200 mmH
2O in opening pressure. Panangiography revealed a larger aneurysm in the trifurcation of the right middle cerebral artery and a smaller one in the anterior communicating artery. On the 7th admission day, the patient underwent right front-temporal craniotomy under normothermia which disclosed diffuse subarachnoid hemorrhage over the frontal lobe and in the Sylvian fissure. Neck clipping was done with week clip to the middle cerebral artery aneurysm at first by separating Sylvian fissure and careful procedure was carried out alongside with the very spastic anterior cerebral artery. However, the feeder artery was hard to detect due to severe vasospasm and coating with EDH-adhesive was applied to the anterior communicating artery aneurysm. Postoperative angiography showed perfect neck clipping of the trifureation aneurysm and perfect disappearance of the coated aneurysm. This case taught us that the operative approach in the double aneurysms should aim the ruptured one at first. The patient was back to his executive business work at present without any disability.
CASE #III M.A. 56 y/o male.
Transferred to our neurosurgery on the 3rd day after the onset. His status was semicomatose with left 3rd nerve palsy of moderate degree and severe nuchal rigidity (Hunt grade III). CSF was bloody(190 mmH
2O of opening pressure, 0.5 ml removed). Panangiograp y disclosed double aneurysms in the left pericallosal-callosomarginal bifurcation and in the anterior communicating artery. Careful separation of falx via the left front-temporal craniotomy under normothermia was proceeded. However, abrupt rupture occurred during dissecting the aneurysm vertex, which was controlled by sucker and neck clipping was done with Week clip. Anterior communicating aneurysm was clipped via different route. The patient became clear in consciousness on the 2nd POD and works as a farmer at present.
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