Intentional partial coil occlusion followed by delayed clip application to wide-necked middle cerebral artery aneurysms in patients presenting with severe vasospasm: Report of two cases

Jonathan L. Brisman, Chan Roonprapunt, Joon K. Song, Yasunari Niimi, Avi Setton, Alejandro Berenstein, Eugene S. Flamm

Research output: Contribution to journalArticle

16 Scopus citations

Abstract

The treatment of ruptured cerebral aneurysms in patients presenting with vasospasm remains a particular challenge. The authors treated two patients harboring Hunt and Hess Grade 1 subarachnoid hemorrhages from middle cerebral artery (MCA) aneurysms associated with severe local angiographically demonstrated yet asymptomatic vasospasm on presentation. Because both aneurysms had wide necks and were located at the MCA bifurcation, they were believed to be anatomically suitable for microsurgical clip application. Severe M1 vasospasm was believed to be a relative contraindication to open surgery, however. An intentionally staged endovascular and microsurgical treatment strategy was planned in each patient. Partial coil occlusion of the aneurysmal dome was performed to prevent the lesion from rebleeding and was followed by balloon angioplasty of the spastic vessel. Early treatment of the severe spasm appeared to prevent significant delayed neurological ischemic deficit. Following resolution of the vasospasm, definitive clipping of the aneurysms was performed on Day 13 post embolization. One patient had a good clinical recovery and was discharged without neurological deficit. The other patient's hospital course was complicated by the occurrence of a postoperative posterior temporal infarct requiring partial temporal lobectomy, although she eventually had a good recovery with only a small visual field deficit. Based on data obtained in these two patients, one can infer that ruptured wide-necked MCA aneurysms associated with severe local vasospasm may best be treated using a staged combined treatment plan. Delayed clip application might be performed more safely 4 to 6 weeks postocclusion, or later, than at 2 weeks.

Original languageEnglish (US)
Pages (from-to)154-158
Number of pages5
JournalJournal of neurosurgery
Volume101
Issue number1
DOIs
Publication statusPublished - Jul 2004
Externally publishedYes

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Keywords

  • Angioplasty
  • Clip application
  • Coil occlusion
  • Middle cerebral artery aneurysm vasospasm

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

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