Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms
A 57-year-old woman presented with a one month history of blurred vision in her left eye. She had a 14-year history of hypertension for which she had been prescribed antihypertensive medication. On neuro-ophthalmologic examination, visual acuity measured as 0.9 on both sides by Snellen's chart, and no defects in visual fields or extraocular movements were noted. An unruptured left carotid cave aneurysm measuring 12×10 mm was found (). Prior to planning surgical clipping, collateral circulation tolerance was confirmed with BTO during the preoperative DSA. The cervical ICA was exposed for proximal control and OZA with anterior clinoidectomy, and resection of the DDR was performed as part of a routine procedure to expose the proximal neck of the aneurysm. The intraoperative MEP and VEP were also monitored. During the tandem clipping and reconstruction of the aneurysm, an intraoperative rupture occurred. Ten minutes after proximal temporary occlusion of the cervical ICA, the amplitude of the MEP had completely dissipated. However, ten more minutes of proximal cervical ICA temporary occlusion was needed for complete occlusion of the broad aneurysm neck. Four differently shaped fenestrated and two standard clips were used to reconstruct the ICA with preservation of the ophthalmic and posterior communicating arteries (). After re-opening the proximal cervical ICA temporary occlusion, the MEP amplitude had recovered to one-third of normal at the end of surgery. The patient displayed right hemiparesis (grade III) immediately after the operation, but her motor weakness gradually recovered and normalized within six hours after surgery. No other complications were noted in her last follow-up visit.