We chose a segment slightly longer than the length of the fusiform aneurysm in order to avoid pre- and post-wrap-clipping stenosis. While the firm attachment between the inferior falx and the fusiform aneurysm was maintained, a section of the lower thinner part of the falx cerebri firmly attached to the aneurysm was dissected and wrapped around the fusiform aneurysm, stabilized with a fenestrated clip. We present a review of the literature with an illustrative case, with a ruptured fusiform pericallosal artery aneurysm firmly attached to the lower edge of the falx cerebri and not amenable to endovascular intervention. However, there is no available literature on use of the falx cerebri for wrap-clipping. Various techniques have been used for wrap-clipping a ruptured, fusiform intracranial aneurysm. Their availability makes them first-line options for low-income settings. Conclusion: Microsurgical options achieved good outcomes in the management of ruptured aneurysms in our series. The good outcome was higher among microsurgery groups (73.7%) compared to the coiling group (63.6%) but this difference did not achieve statistical significance (χ 2 = 0.46 P = 0.4976). Overall, 72.7% of those treated had a good outcome (Glasgow Outcome Score of 4 and 5). Ictus-intervention interval (χ 2 = 10.034, P = 0.007) and multiple surgical procedures (χ 2 = 8.9341, P = 0.003) were the significant outcome determinants. ACOM was the most common site for ruptured aneurysm. Coiling was performed for 11 (10%) patients. Microsurgical options such as wrapping, bypass, and excision were performed for 9 (8.2%) patients. Ninety (81.8%) patients received microsurgical clipping. The mean age was 50.8 years (standard deviation ☑3.5) for females and 50.2 (SD ± 12.4) for males (P = 0.8112, t-test). Results: One hundred and ten patients were studied. Data analysis was performed with SPSS for Windows, version 21. It was performed on patients with aneurysmal rupture managed from June 2010 to October 2016. Materials and Methods: This was a single institution questionnaire-based retrospective study from West Bengal India. For locations with limited capacity or evolving endovascular service, however, microsurgical treatment offers not only cost-effective and durable options but also oftentimes the only option available for most patients. However, recent advances in endovascular techniques have broadened their application stimulating much debate regarding the usefulness of microsurgical options. It can prevent rebleeding and represents an improvement when compared with the natural history.īackground: Microsurgical clipping and endovascular coiling have remained over the past half-century, the main options for definitive treatment of ruptured intracranial aneurysms. One patient deceased due to pulmonary tromboembolism.Ĭlip-wrap techniques for the treatment of fusiform and otherwise unclippable aneurysms seem to be safe and it can be associated with a low rate of acute or delayed postoperative complications. No early or late rebleeding was observed after 2 years mean follow-up. Three were dolichoectatic, 4 were unsuitable to complete surgical clipping because parent or efferent vessels arises from the aneurysm sac (1 MCA, 1 AcomA, 1 CO, 1 PICA aneurysms) and two, although ruptured aneurysms, were too small (<2mm) to be directly clipped. The aneurysms were located at middle cerebral artery (2), anterior choroidal artery (1), anterior communicating artery (1), carotid ophthalmic (3), posterior cerebral artery (1) and posterior-inferior cerebellar artery (1). In the last four years, 9 cases of ruptured aneurysms treated by the clip-wrap techniques were identified in the Division of Neurological Surgery, University of São Paulo, School of Medicine. To report a series of nine cases of otherwise untreatable aneurysms managed using the clip-wrap technique and discuss its surgical nuances. Nonetheless, these alternatives methods of treatment have been underused and frequently overlooked. Treatment of these aneurysms often requires alternative surgical strategies, including extracranial-intracranial bypass, wrapping, or clip-wrap techniques. Fusiform and dolichoectatic aneurysms are challenging lesions to treat with direct clipping.
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