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We describe the case of a 51-year-old woman who underwent craniotomy and surgical clipping of a large internal carotid bifurcation aneurysm that was refractory to treatment with 2 rounds of endovascular coiling and internal carotid artery (ICA) to middle cerebral artery pipeline placement. The patient initially presented in 2004 with a 3-week history of sudden-onset headache with associated nausea. Computed tomography and lumbar puncture on presentation in 2004 were negative for subarachnoid hemorrhage. Digital subtraction angiography, however, demonstrated a large left ICA bifurcation aneurysm. The decision was made to proceed with endovascular coiling of the aneurysm. Six-month and 1-year follow-up imaging showed incomplete resolution of the aneurysm, and retreatment coiling was completed in 2005. After recoiling in 2005, the patient was lost to follow-up. During this period, she underwent pipeline placement from the ICA to the middle cerebral artery across the A1 segment at a different institution. Two years after flow diversion, the patient was referred back to our institution with further worsening of the aneurysm. Our surgical team opted for craniotomy and surgical clipping given the limited management options that this extremely complex case now presented. The patient consented to the procedure. Postoperative imaging demonstrated marked improvement in aneurysm severity. Although the current neurosurgical trend favors endovascular treatment over craniotomy, this case shows the vital importance of craniotomy and aneurysm clipping in the treatment of select patients. We also provide high-quality operative video of aneurysm clipping. 1-7
Fisher et al. (Thu,) studied this question.