Abstract
A 57-year-old woman presented with a progressive deterioration of vision. She had previously undergone clipping for a ruptured small anterior communicating artery (Acom) aneurysm 7 years prior to admission and additional coiling for recurrence 2 years prior to admission. Angiography showed regrown out-pouching of the sac, which measured 27 × 18 mm. A decision was made to perform surgical treatment to alleviate the mass effect of the aneurysm. Unique techniques for revision of the scarred surgical corridor, removal of old clips, resection of the coiled mass, thrombectomy, and intra-aneurysmal endarterectomy were required to allow placement of the final clips. The patient recovered uneventfully, and her vision was satisfactorily restored.
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The case reported by Kim et al. illustrates a very positive evolution after surgical treatment of a giant ACoA aneurysm already treated twice, first by surgical clipping and second by coil embolization, and responsible for vision deterioration. The authors can be commended for this result. All neurosurgeons dealing with failed coiled aneurysms know the difficulties of being confronted with a large fundus full of coils that is not very movable. This case stresses that an aneurysm, even treated twice, can still slowly grow from 5 mm diameter to 27 mm and develop a mass effect. It confirms the necessity of an angiographic control not only a few months after coil embolization, but also 2 or 3 years after treatment. That there was no cognitive problem at all even after a 22 min 46 s long trapping remains remarkable and probably is the indirect sign of a progressive collateral vascularization of the brain ACoA territory. As the authors did, it is important to emphasize, in case of recanalization post embolization, the necessity of a careful evaluation of the aneurysm recurrence. Indeed, neurosurgeons should wait for a significant recurrence (type A) allowing a direct clip application without fundus resection (type B) (1). The complementarity between neurosurgeons and endovascular radiologists must be a prerequisite before dealing with ICA in order to choose the most effective treatment with the lowest risk and the best stability without a competitive spirit, but only the best interest for our patients.
1. Raftopoulos C, Vaz G, Docquier M, Goffette P (2007) Neurosurgical management of inadequately embolized intracranial aneurysms: a series of 17 consecutive cases. Acta Neurochir (Wien) 149:11–19; discussion 18–19
Christian Raftopoulos
University Hospital St-Luc, Belgium
This work was supported in part by grant no. 2008-38 from the Clinical Research Council of the National Health Insurance Corporation, Ilsan Hospital, Koyang, Korea.
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Kim, Y.B., Lee, J.W., Lee, K.C. et al. Techniques of reoperation for a giant regrown anterior communicating artery aneurysm harboring long-implanted clips and compacted coil mesh. Acta Neurochir 151, 613–618 (2009). https://doi.org/10.1007/s00701-009-0318-1
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DOI: https://doi.org/10.1007/s00701-009-0318-1