| Title: | Tulip Giant Aneurysm Amputation and 'Shingle Clip Cut Clip' Technique for Microsurgical Reconstruction of a Giant Thrombosed Middle Cerebral Artery Aneurysm |
| Author(s): | Bendok BR; Abi-Aad KR; Rahme RJ; Turcotte EL; Welz ME; Patra DP; Hess R; Kalen B; Krishna C; Batjer HH; |
| Address: | "Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA; Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona, USA; Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA. Electronic address: Bendok.bernard@gmail.com. Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA; Precision Neuro-therapeutics Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA; Neurosurgery Simulation and Innovation Laboratory, Mayo Clinic, Phoenix, Arizona, USA. Department of Neurologic Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA" |
| DOI: | 10.1016/j.wneu.2019.07.192 |
| ISSN/ISBN: | 1878-8769 (Electronic) 1878-8750 (Linking) |
| Abstract: | "In this video, we present the case of a 61-year-old female who was brought to the emergency department after she had partial complex seizures. Computed tomography and magnetic resonance imaging of the brain revealed a right temporal lobe mass, which was initially thought to be a tumor. The patient was therefore referred to us for further management. The round nature of the lesion raised suspicion for an aneurysm. Computed tomography angiography was performed, followed by a diagnostic conventional cerebral angiogram, and confirmed the presence of a giant thrombosed aneurysm. Giant aneurysms represent 3%-5% of all cerebral aneurysms.(1) They are more common in females with a ratio of 2:1 to 3:1.(1) They have a high risk of rupture up to 50% in the posterior circulation and 40% in the anterior circulation over 5 years according to the International Study of Unruptured Intracranial Aneurysms Investigators.(2,3) Their treatment can be complex and treacherous. Treatment options vary widely from parent artery sacrifice in select cases to clip reconstruction to an array of endovascular approaches such as flow diversion. In some cases a combination of both open and endovascular approaches might be necessary.(4-8) In our case, we opted for an open surgical clip reconstruction. A superior temporal artery-middle cerebral artery bypass was attempted to allow for trapping of the aneurysm without risking ischemic complication distal to it. Unfortunately, the patient's vessels were too atherosclerotic to maintain patency. A strategy was then devised, which consisted of cutting the dome of the aneurysm and clearing the distal two thirds of the clot ('tulip technique') and then completing thrombus resection under temporary occlusion. Once clot removal was completed, the aneurysm was clipped using the 'shingle clip cut clip' technique (Video 1). The patient's postoperative course was uneventful, and the patient remained seizure free" |
| Keywords: | "Female Humans Infarction, Middle Cerebral Artery/*surgery Intracranial Aneurysm/*surgery Microsurgery/*methods Middle Aged Middle Cerebral Artery Neurosurgical Procedures/methods Plastic Surgery Procedures/methods Surgical Instruments Giant aneurysm Shing;" |
| Notes: | "MedlineBendok, Bernard R Abi-Aad, Karl R Rahme, Rudy J Turcotte, Evelyn L Welz, Matthew E Patra, Devi P Hess, Ryan Kalen, Brian Krishna, Chandan Batjer, Hunt H eng Case Reports Video-Audio Media 2019/08/05 World Neurosurg. 2019 Nov; 131:166. doi: 10.1016/j.wneu.2019.07.192. Epub 2019 Aug 2" |
