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Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 22-24

Surgical nuances of clip reconstruction of recurrent middle cerebral artery aneurysms: A technical note

1 Department of Neurosurgery, Stanley Medical College, Chennai, Tamil Nadu, India
2 Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan

Date of Submission05-Jul-2021
Date of Decision19-Jul-2021
Date of Acceptance29-Jul-2021
Date of Web Publication27-Aug-2021

Correspondence Address:
Dr. Aravind Sabesan
Department of Neurosurgery, Stanley Medical College, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcvs.jcvs_17_21

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Recurrence of an aneurysm is not frequently seen after microsurgical clipping. The exact incidence is varied among studies related to recurrent aneurysms from 0.02% to 0.52%. A 68-year-old male, diagnosed with unruptured left middle cerebral artery (MCA) aneurysm 8 years back, was treated by microsurgical clipping then. He was on periodic follow-up since. On yearly follow-up, in 2015, magnetic resonance imaging/magnetic resonance angiography showed small recurrent aneurysm. This was followed up with serial imaging, and the aneurysm slowly grew in size. 2 years after, he was found to have a recurrent aneurysm; in 2017, he was operated for the recurrent aneurysm with microsurgical clipping. Here, we report the technical difficulties and strategies to approach recurrent MCA aneurysm.

Keywords: Aneurysm, clip reconstruction, middle cerebral artery, surgery

How to cite this article:
Sabesan A, Kato Y, Kawase T, Yamada Y, Tanaka R. Surgical nuances of clip reconstruction of recurrent middle cerebral artery aneurysms: A technical note. J Cerebrovasc Sci 2021;9:22-4

How to cite this URL:
Sabesan A, Kato Y, Kawase T, Yamada Y, Tanaka R. Surgical nuances of clip reconstruction of recurrent middle cerebral artery aneurysms: A technical note. J Cerebrovasc Sci [serial online] 2021 [cited 2023 Mar 28];9:22-4. Available from: http://www.jcvs.in/text.asp?2021/9/1/22/324813

  Introduction Top

Patients with completely obliterated ruptured aneurysms still carry a relatively high risk for recurrent subarachnoid haemorrhage (SAH) secondary to de novo aneurysm formation or regrowth of the original aneurysms. Multiple studies have proved long-term efficacy of clipping unruptured aneurysms; still, the risk of SAH is high compared with that in the general population, even after treatment.[1] We describe a case of recurrent middle cerebral artery (MCA) aneurysm 8 years after microsurgical clipping.

  Case Report Top

A 68 year old male patient presented with an un-ruptured left MCA aneurysm, for which microsurgical clipping done was performed was 8 years back. On regular follow-up for the past 8 years with yearly imaging to assess the clipping status and also de novo new aneurysm development, the patient was found to have a recurrence in the left MCA in 2015. Initially found to be small in size, the patient was counselled, and it was decided to wait and watch for serial imaging to assess the rate of aneurysm growth. On serial imaging, it was found that the aneurysm increased in size significantly [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d. It was decided to be re-operated by the senior author (Y.K.).
Figure 1: (a-d) Three-dimensional reconstruction images showing the recurrent right middle cerebral artery aneurysm and previous clips in situ

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After undergoing all necessary pre-operative evaluation, the patient was posted for elective re-exploration and clipping of the recurrent aneurysm. The skin was explored through the previous incision. The bone flap replaced in the previous surgery was found to be adequate through review of three-dimensional computed tomography (3DCT). No extra bone was removed. It was found during the 3DCT analysis that three clips were used in the first surgery, and one of the clips was jutting out of the Sylvian fissure and lying close to the overlying dura [Figure 2]. Hence, it was decided to use Dual Intraoperative Visualization Approach (DIVA) before opening the dura to avoid injuring the Sylvian veins, if adherent to the dura. The dura was opened under the microscope. There were adhesions between the dura and the cortical surface and between the dura and the aneurysm clip [Figure 3]. The dura could not be separated from the clip, and hence, a cuff of dura was left adherent to the clip and dura opened to expose the Sylvian fissure.
Figure 2: Previous aneurysm clip seen jutting out of the Sylvian Fissure

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Figure 3: Previous aneurysm clip seen densely adherent to the dura

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With a combination of suction irrigation/dynamic retraction and sharp dissection, the aneurysm sac was dissected off the frontal and the temporal lobes. Proximal M1 segment was dissected and identified first. Now that the sac was dissected, the cuff of dura adherent to the aneurysm clip was cut and removed. Dissecting around the aneurysm bifurcation with the help of an endoscope, the aneurysm morphology was identified. The recurrent aneurysm was clipped with the combination of curved and fenestrated clips. After clipping the aneurysm and reconstructing the bifurcation, flow was confirmed by - Indo-Cyanine Green/Dual Intraoperative Visualization Approach (ICG/DIVA) and endoscope [Figure 4]a and [Figure 4]b. The post-operative period was uneventful.
Figure 4: (a) Recurrent aneurysm before clipping, (b) post-reconstruction, with complete obliteration of the aneurysm

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  Discussion Top

The development of aneurysms should not be considered a once in-a-lifetime event, but rather a continuous process.[2]

Management of recurrent aneurysms becomes difficult if the parent artery at the level of the neck insertion has a dysplastic wall, which is frequently found in majority of the recurrent cases.

It has been observed that fragility of the vascular wall at the clip edge may lead to regrowth in the setting of haemodynamic stress. Arterial medial wall defects and hypertension may play a role in aneurysm recurrence or the development of de novo aneurysms.

The main goal in the treatment of cerebral aneurysm is complete obliteration of the aneurysmal sac and neck. Surgical treatment for recurrence of a previously clipped aneurysm is one of the most difficult procedures in aneurysm surgery. A general trend towards endovascular treatment of aneurysms diminishes the likelihood that neurosurgeons will perform repeat clipping due to significant technical difficulty and fear of complications.[2]

Clipping can be safer if there is lack of larger branches extending from the aneurysmal dome and a suitable location for the safe dissection of the aneurysm using the related arteries.[2]

Difficulty in such surgeries pertains to surgical adhesions, conglomeration of old clips, vessels, and surrounding brain or cranial nerves incorporated into tight scar tissue. This requires an extremely high level of dexterity and surgical experience. Tiny perforators are sometimes obscured by scar adherent to the clips. Scar tissue, adherent surgical planes, friability of the cortex and vessels, and dealing with the prior clip placement, can reduce the ideal visibility for the trajectory of the clip placement.

Five important steps during the procedure should be meticulously planned for repeat cases. These include (1) dissection toward the aneurysm, (2) bypass assistance if necessary, (3) mobilization of the old clip (s), (4) removal of coils and thrombus, and (5) placement of the new clip.[2]

Recurrent aneurysm was defined as regrowth of an aneurysm after neck clipping or rupture of a remnant after neck clipping.

In the study by Tsutsumi et al., a mean follow-up of 9 years reported an annual incidence of 0.26% in a series of 125 patients.[3] In another study, David et al. reported an annual regrowth rate of 0.52% for completely clipped aneurysms in a series of 135 patients followed for 4.4 years.[4]

As Nakayama defined the concept, the closure plane is that plane in which the ideal closure line is included. In most cases, the ideal closure line is curved, so the only ideal closure plane is defined for the particular aneurysm according to the ideal closure line.[5]

Kobayashi et al. classified recurrent aneurysms based on both the lines and planes into four types and defined clearly the treatment guidelines for each type.[6]

Spiotta et al. categorized 26 recurrent aneurysms from two institutions into three types, which were the simplest of all classifications.[7]

el-Beltagy et al. classified recurrent aneurysms based on aneurysm relationship to the clip; this was useful to analyse whether to retain or remove the clips.[8]

Ishikawa et al. defined the closure line as the line on the aneurysm caused by clipping and demonstrated that the ideal closure line on each aneurysm can be identified to eliminate the aneurysm as far as possible. This concept can be theoretically comprehended and accepted by most neurosurgeons, since clipping refers to the task of converting the aneurismal orifice as a 3D curved sphere into a 2D curved line.[9]

  Conclusion Top

The rapid advent of endovascular devices, such as flow diversion, brings even more promise of treating these treacherous lesions but may not always provide a perfect solution due to the complexity of branching patterns and need to preserve collaterals and distal vasculature. Even worse is the complex morphology of such aneurysms and propensity to grow rapidly making treatment even more difficult. While treating recurrent aneurysms, it is imperative to do a complete imaging study with 3D reconstruction and use all surgical adjuvants such as ICG/DIVA/endoscope to successfully clip the recurrent aneurysm. This case report brings out the nuances and the technical difficulty in successfully treating a recurrent aneurysm.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Tsutsumi K, Ueki K, Usui M, Kwak S, Kirino T. Risk of recurrent subarachnoid hemorrhage after complete obliteration of cerebral aneurysms. Stroke 1998;29:2511-3.  Back to cited text no. 1
Kivelev J, Tanikawa R, Noda K, Hernesniemi J, Niemelä M, Takizawa K, et al. Open surgery for recurrent intracranial aneurysms: Techniques and long-term outcomes. World Neurosurg 2016;96:1-9.  Back to cited text no. 2
Tsutsumi K, Ueki K, Usui M, Kwak S, Kirino T. Risk of subarachnoid hemorrhage after surgical treatment of unruptured cerebral aneurysms. Stroke 1999;30:1181-4.  Back to cited text no. 3
David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 1999;91:396-401.  Back to cited text no. 4
Nakayama N. How to take the closure line in the anterior communicating artery aneurysm clipping. Closure 'Plane' concept and approach selection. Curr Pract Neurosurg 2009;19:998-1010.  Back to cited text no. 5
Kobayashi S, Moroi J, Hikichi K, Yoshioka S, Saito H, Tanabe J, et al. Treatment of recurrent intracranial aneurysms after neck clipping: Novel classification scheme and management strategies. Neurosurgery 2017;13:670-8.  Back to cited text no. 6
Spiotta AM, Hui F, Schuette A, Moskowitz SI. Patterns of aneurysm recurrence after microsurgical clip obliteration. Neurosurgery 2013;72:65-9.  Back to cited text no. 7
el-Beltagy M, Muroi C, Roth P, Fandino J, Imhof HG, Yonekawa Y. Recurrent intracranial aneurysms after successful neck clipping. World Neurosurg 2010;74:472-7.  Back to cited text no. 8
Ishikawa T, Nakayama N, Moroi J, Kobayashi N, Kawai H, Muto T, et al. Concept of ideal closure line for clipping of middle cerebral artery aneurysms – Technical note. Neurol Med Chir (Tokyo) 2009;49:273-7.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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