• Journal of Korean Neurosurgical Society
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• v.43 no.1
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• pp.21-25
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• 2008

Objective : Both endovascular coil embolization and microsurgical clipping are now firmly established as treatment options for the management of cerebral aneurysms. Moreover, they are sometimes used as complementary approaches each other. This study retrospectively analyzed our experience with endovascular and microsurgical procedures as complementary approaches in treating a single aneurysm. Methods : Nineteen patients with intracranial aneurysm were managed with both endovascular and microsurgical treatments. All of the aneurysms were located in the anterior circulation. Eighteen patients presented with SAH, and 14 aneurysms had diameters of less than 10 mm, and five had diameters of 10-25 mm. Results : Thirteen of the 19 patients were initially treated with endovascular coil embolization, followed by microsurgical management. Of the 13 patients, 9 patients had intraprocedural complications during coil embolization (intraprocedural rupture, coil protrusion, coil migration), rebleeding with regrowth of aneurysm in two patients, residual sac in one patient, and coil compaction in one patient. Six patients who had undergone microsurgical clipping were followed by coil embolization because of a residual aneurysm sac in four patients, and regrowth in two patients. Conclusion : In intracranial aneurysms involving procedural endovascular complications or incomplete coil embolization and failed microsurgical clipping, because of anatomical and/or technical difficulties, the combined and complementary therapy with endovascular coiling and microsurgical clipping are valuable in providing the best outcome.

• Journal of Korean Neurosurgical Society
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• v.54 no.6
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• pp.477-483
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• 2013

Objective : Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications. Methods : Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography. Results : Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely. Conclusion : The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.4
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• pp.475-484
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• 2023

Objective: This study aimed to develop microsurgical strategies based on the anatomical relationship between dorsal internal carotid artery (ICA) aneurysms, the falciform ligament (FL), and the anterior clinoid process (ACP). Methods: Between 2017 and 2022, 25 patients with unruptured dorsal ICA aneurysms (less than 4 mm in diameter) underwent microsurgical direct clipping. These cases involved the left ICA (n=17) and the right ICA (n=8), with a mean aneurysm size of 3.3 mm (range, 2.5 to 4 mm). We used computed tomography angiography (CTA) and digital subtraction angiography to elucidate the anatomical relationship between dorsal ICA aneurysms and other structures. All procedures involved an ipsilateral pterional approach with securement of the ipsilateral cervical ICA for proximal control. Results: Among the 25 dorsal ICA aneurysms, 8 (32%) were clipped without the FL being incised. Another 5 (20%) were clipped solely after the FL was cut. For the remaining 12 cases, the aneurysms were successfully clipped following FL incision and partial ACP removal. Patients exhibited favorable postoperative recoveries with good outcomes, and postoperative CTA revealed complete aneurysm clipping without any residual remnants. Conclusions: We were able to perform clipping without removing the ACP in 13 patients (52%), and in 8 of these (32%), the clipping was carried out directly without cutting the FL. Microsurgery, coupled with proximal control of the cervical ICA, can serve as a viable alternative for patients with small dorsal ICA aneurysms, especially when endovascular treatment options are limited, and 3D CTA confirms a clear anatomical relationship with the ACP.

• Journal of Korean Neurosurgical Society
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• v.53 no.6
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• pp.371-373
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• 2013

Intracranial aneurysms in the neonate are very rare and their clinicopathological findings remain unclear. We report a 26-day-old premature neonate who underwent microsurgical clipping on the ruptured middle cerebral artery bifurcation aneurysm successfully with a review of relevant literature.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.3
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• pp.340-346
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• 2023

Bilateral distal anterior cerebral artery (DACA) aneurysms also called "kissing aneurysms" or "mirror aneurysm" are extremely rare, accounting for only 0.2% of all intracranial aneurysms. There have only been a few examples of mirror DACA aneurysms reported in the literature. Here, we report a rare case of mirror DACA aneurysm in a middle aged female with its successful clipping. Patient was admitted with severe headache and altered sensorium. Computed tomography (CT) head was suggestive of anterior inter-hemispheric hematoma. Digital subtraction angiography (DSA) was done which was suggestive of two distal anterior cerebral artery aneurysms located at same anatomical position. It was treated through microsurgical clipping. Mirror image DACA aneurysms are rare occurrence. All patients with ruptured DACA aneurysms should have angiography with 3D reconstruction studies. This aids in determining the aneurysm's morphology and planning treatment accordingly.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.4
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• pp.447-451
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• 2023

Developmental anomalies of internal carotid artery (ICA), being rare entities, are mostly asymptomatic by themselves because of good collateral supply. However, when present with other associated intracranial anomalies requiring treatment, there can be catastrophic consequences, if special attention is not paid to this condition. We present a case of 36 years old male, who reported to our emergency department with complaints of headache and loss of consciousness. He was diagnosed as a case of ruptured anterior communicating aneurysm with subarachnoid hemorrhage and agenesis of left ICA with trans-cavernous anastomosis. He underwent clipping of aneurysm and was discharged uneventfully. This report highlights the importance of skillful microsurgical clipping in extremely high-risk conditions, in contemporary era of hybrid neurosurgeons.

• Journal of Korean Neurosurgical Society
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• v.48 no.3
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• pp.199-206
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• 2010

Objective : Paraclinoid segment internal carotid artery (ICA) aneurysms have historically been a technical challenge for neurovascular surgeons. The development of microsurgical approach, advances in surgical techniques, and endovascular procedures have improved the outcome for paraclinoid aneurysms. However, many authors have reported high complication rates from microsurgical treatments. Therefore, the present study reviews the microsurgical complications of the extradural anterior clinoidectomy for treating paraclinoid aneurysms and investigates the prevention and management of observed complications. Methods : Between January 2004 and April 2008, 22 patients with 24 paraclinoid aneurysms underwent microsurgical direct clipping by a cerebrovascular team at a regional neurosurgical center. Microsurgery was performed via an ipsilateral pterional approach with extradural anterior clinoidectomy. We retrospectively reviewed patients' medical charts, office records, radiographic studies, and operative records. Results : In our series, the clinical outcomes after an ipsilateral pterional approach with extradural anterior clinoidectomy for paraclinoid aneurysms were excellent or good (Glasgows Outcome Scale : GOS 5 or 4) in 87.5% of cases. The microsurgical complications related directly to the extradural anterior clinoidectomy included transient cranial nerve palsy (6), cerebrospinal fluid leak (1), worsened change in vision (1), unplanned ICA occlusion (1), and epidural hematoma (1). Only one of the complications resulted in permanent morbidity (4.2%), and none resulted in death. Conclusion : Although surgical complications are still reported to occur more frequently for the treatment of paraclinoid aneurysms, the permanent morbidity and mortality resulting from a extradural anterior clinoidectomy in our series were lower than previously reported. Precise anatomical knowledge combined with several microsurgical tactics can help to achieve good outcomes with minimal complications.

• Journal of Korean Neurosurgical Society
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• v.37 no.3
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• pp.179-186
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• 2005

Objective: The purpose of this paper is to report our experiences in managing seventeen cases of residual intracranial aneurysms following surgical or endovascular treatment and discuss the incidence of residual aneurysms, the indications and technique of retreatment of residual aneurysms. Methods: During a period of 42 months, we treated 391 aneurysms in 339 patients with microsurgical clipping or GDC embolization as a primary treatment. In 39 of them, follow-up angiography revealed residual aneurysms and seventeen of whom were retreated. There were eleven cases in ACoA, three cases in distal ICA, one, in each of MCA, ACA and basilar artery. We reviewed retrospectively the clinical notes, operation records and cerebral angiograms of seventeen patients who had been treated for residual aneurysms. Results: Complementary treatment was performed in 8 cases by means of surgery and in 9 cases by means of GDC embolization. There were eleven females and six males with an age variation between 29 and 78 years. The mean duration of angiographic follow-up was 17.3 months. Of the seventeen cases that were treated for residual aneurysms, fourteen achieved complete occlusion. Of 17 retreated patients, fifteen patients had good recovery according to the Glasgow Outcome Scale. Conclusion: When occlusion after endovascular or surgical treatment is incomplete, a new multidisciplinary approach should be carried out. Given our experiences, we recommend coil embolization of the choice in cases that the residual aneurysmal neck had been narrowed by previous clipping. On the other hand, if the residual aneurysm has enough space to clip but not enough to coil, we recommend the microsurgical clipping.

• Journal of Korean Neurosurgical Society
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• v.66 no.4
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• pp.418-425
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• 2023

Objective : Deciphering the anatomy of posterior communicating artery (PCoA) aneurysms in relation to surrounding structures is essential to determine adjuvant surgical procedures. However, it is difficult to predict surgical structures through preoperative imaging studies. We aimed to present anatomical structures using preoperative high-resolution three-dimensional proton density-weighted turbo spin-echo magnetic resonance (PDMR) imaging with simple classification. Methods : From January 2020 to April 2022, 30 patients underwent PDMR before microsurgical clipping for unruptured PCoA aneurysms in a single tertiary institute. We retrospectively reviewed the radiographic images and operative data of these patients. The structural relationship described by PDMR and intraoperative findings were compared. Subsequently, we classified aneurysms into two groups and analyzed the rate of adjuvant surgical procedures and contact with the surrounding structures. Results : Correlations between preoperative PDMR predictions and actual intraoperative findings for PCoA aneurysm contact to the oculomotor nerve, temporal uncus, and anterior petroclinoid fold (APCF) reported a diagnostic accuracy of 0.90, 0.87, and 0.90, respectively. In 12 patients (40.0%), an aneurysm dome was located on the plane of the oculomotor triangle and was classified as the infratentorial type. Compared to the supratentorial type PCoA aneurysm, adjuvant procedures were required more frequently (66.7% vs. 22.2%, p=0.024) for infratentorial type PCoA aneurysm clipping. Conclusion : Preoperative PCoA aneurysm categorization using PDMR can be helpful for predicting surgical complexity and planning of microsurgical clipping.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.2
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• pp.150-159
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• 2023

Objective: The aim of this study was to investigate the efficacy of intraoperative indocyanine green videoangiography (ICG-VA) and intraoperative neuromonitoring (IONM) to prevent postoperative ischemic complications during microsurgical clipping of unruptured anterior choroidal artery (AChA) aneurysms. Methods: We retrospectively reviewed the clinical and radiological records of all patients who had undergone microsurgical clipping for unruptured AChA aneurysms at our institution between April 2001 and December 2019. We compared the postoperative complication rate of the group for which intraoperative ICG-VA and IONM were utilized (group B; n=324) with that of the group for which intraoperative ICG-VA and IONM were not utilized (group A; n=72). Results: There were no statistically significant differences in demographic data between the two groups. Statistically significant differences were observed in the rate of overall complications (p=0.014) and postoperative ischemic complications related to AChA territory (p=0.039). All the cases (n=4) in group B who had postoperative infarctions related to AChA territory showed false-negative results of intraoperative ICG-VA and IONM. Conclusions: Preserving the patency of the AChA is essential to minimize postoperative complications. Intraoperative monitoring tools including ICG-VA and IONM can greatly contribute to lowering complication rates. However, their pitfalls and false-negative results should always be considered.