Supraclinoid Internal Carotid Artery Fenestration Harboring an Unruptured Aneurysm and Another Remote Ruptured Aneurysm: Case Report and Review of the Literature
A 44-year-old male presented with severe sudden-onset headache. Computed tomography (CT) scan showed dense blood clot in the left Sylvian fissure, suggesting ruptured middle cerebral artery (MCA) bifurcation aneurysm; CT angiography (CTA) revealed another supraclinoid ICA aneurysm as well as left MCA bifurcation aneurysm (). For the treatment of ruptured MCA bifurcation aneurysm, considering the irregular shape, larger size, daughter sac and the location of the hematoma in preoperative CT scan, the patient underwent aneurysm clipping surgery via a left pterional craniotomy. A clip was successfully placed on the neck of the aneurysm, which was confirmed as ruptured in the surgical field. Although a paraclinoid aneurysm existed on the same side and could be clipped via the same approach, we planned endovascular treatment for the unruptured supraclinoid ICA aneurysm because of potential optic nerve injury attributable to anterior clinoidectomy or unroofing of the optic canal during clipping. The three-dimensional rotational angiography (3DRA) at 20 days after surgery demonstrated a fenestration of the left supraclinoid ICA with an aneurysm arising from its proximal end, which was not delineated clearly on 2D cerebral angiography and CTA, and the well-clipped state of the ruptured MCA bifurcation aneurysm. The fenestration of the ICA occurred from the origin of the ophthalmic artery (OphA) to the origin of the posterior communicating artery (PCoA). A saccular aneurysm was oriented postero-laterally, arising from the posterior aspect of the left supraclinoid ICA segment, which was proximal to the fenestration (). The aneurysm was 4.5, 3.4 and 3.5 mm in length, dome and neck diameter, respectively. From post-operative day 20, dual anti-platelet medication (aspirin 200 mg and clopidogrel 75 mg) was administered for about seven days for the coil embolization of the supraclinoid ICA aneurysm. At 27 days after the surgical clipping, because of the wide-neck and vessel incorporation at the neck of the aneurysm, balloon-assisted endovascular coiling was performed to occlude the aneurysm and preserve both fenestration channels. Under local anesthesia, the 7F femoral sheath was inserted through the right-sided femoral artery. Then the 7F guiding catheter (Vista Brite; Cordis Neurovascular, Miami, FL) was advanced to the distal cervical ICA segment. The Excelsior SL-10 microcatheter (Boston Scientific, Natick, MA) was placed into the neck of the aneurysm. Balloon-assisted coil embolization was done with Hyperglide [Microtherapeutics (MTI), Irvine, CA]. We used five bare-platinum coils for the obliteration of the aneurysm. The aneurysm was obliterated successfully, and both limbs of the fenestration were preserved (). The patient had an uneventful postoperative course and was discharged without any neurological deficits.