Single-stage clipping with bifrontal and bilateral frontotemporal craniotomies for subarachnoid hemorrhage with multiple cerebral aneurysms using Sugita head holding system: A case report

Abstract

Background: Subarachnoid hemorrhage with multiple aneurysms is very challenging because it is difficult to identify the ruptured aneurysm. We could not identify the ruptured aneurysm preoperatively, so we decided to treat all of the aneurysms as a single-stage surgery.

Case description: A 79-year-old woman was diagnosed with subarachnoid hemorrhage with multiple cerebral aneurysms at the right distal anterior cerebral artery, left middle cerebral artery, and right internal carotid artery- posterior communicating artery bifurcation. We could not identify the ruptured aneurysm preoperatively. We fixed her head using the Sugita head holding system (Mizuho Co., Ltd., Tokyo) and performed clipping for each aneurysm with bifrontal craniotomy and bilateral frontotemporal craniotomy as a single-stage operation. The last aneurysm seemed ruptured, and clipping for all the aneurysms was successful. She was discharged with a good postoperative course. The Sugita head holding system allowed turning the head of the patient toward the right and left with single fixation, leading to this single-stage operation.

Conclusion: Several methods for identifying a ruptured aneurysm from multiple aneurysms have been reported, but under limited medical resources, this procedure would be one of the treatment strategies.

Keywords: Craniotomy; Multiple aneurysms; Single-stage operation; Subarachnoid hemorrhage; Sugita head holding system.

Figure 1:

Head computed tomography diagnosed diffuse subarachnoid hemorrhage (a and b). Computed tomography angiography revealed multiple cerebral aneurysms at the right distal anterior cerebral artery (rt. DACA) of 2.4 mm in diameter (red circle in c), left middle cerebral artery (lt. MCA) of 2.3 mm (green circle in c), and right internal carotid artery-posterior communicating artery bifurcation (rt. IC-PC) of 2.1 mm (circle in d). Intraoperative findings of the rt. DACA aneurysm (e) and the lt. MCA aneurysm (f), which seemed unruptured either. Intraoperatively, the IC-PC aneurysm had fibrin cap (arrow in g) and seemed as ruptured (g). After clipping these aneurysms, we closed the cranium with metal plates, and these procedures were performed as a single-stage operation (h). Schematic illustration of the Sugita head holding system (Mizuho Co., Ltd., Tokyo). It allowed turning the head of the patient toward the right and left with single fixation and performing this single-stage operation (i).