Rescue endovascular treatment for rapid regrowth of aneurysm remnant on middle cerebral artery trunk after unsuccessful surgical clipping in patients with a ruptured cerebral aneurysm: A report of two cases

Abstract

We report two rare cases treated with coiling after rapid regrowth (within a month) of an aneurysm remnant on the middle cerebral artery (MCA) trunk after incomplete surgical clipping. The first case, a 47-year-old man with subarachonoid hemorrhage (SAH) (Hunt-Hess grade II, Fisher grade III) underwent clipping of a ruptured saccular aneurysm with a wide neck on the right early frontal branch arising from the MCA trunk. Incomplete clipping with a 1 mm sized remnant neck was performed to avoid sacrificing the lenticulostriate artery. In a follow-up cerebral angiogram on postoperative day 30, a rapid regrowth of the aneurysm remnant was observed, and on that day, complete obliteration was obtained by rescue endovascular treatment. The second case, a 48-year-old healthy woman with SAH (Hunt-Hess grade II, Fisher grade III) underwent clipping of an anteroposteriorly projecting bilobulated aneurysm on the left M1. Incomplete clipping with a minimal remnant neck was performed. In follow-up digital subtraction angiogram on postoperative day 30, a rapid regrowth of an aneurysm remnant involving only a part of the initial aneurysm near the neck was observed, and on that day, complete obliteration was obtained by rescue coiling. These patients were both discharged without any neurological deficits.

Keywords: Incomplete surgical clipping; Middle cerebral artery trunk; Regrowth of aneurysm remnant; ‌Rescue endovascular treatment.

Fig. 1.

A 47-year-old man patient (Hunt- Hess grade II) with subarachnoid hemorrhage (Fisher grade III). Initial three-dimensional reconstruction images in brain computed tomographic angiogram (CTA) revealed a 3.9 mm sized saccular aneurysm (white arrow) with wide neck and it`s neck was incorporated with early frontal branch on right early frontal cortical branch of middle cerebral artery trunk (A). Immediate postoperative CTA demonstrated about 1 mm sized aneurysm remnant (AR, white arrow) behind a clipped aneurysm (white circle) (B: posterior view, C: magnified image in small box). In follow-up digital subtraction angiography (DSA) at postoperative day 30, a rapid regrowth of AR (white arrow) with two blebs (laterally projecting and depth: 7.39 mm×width: 2.58 mm×neck: 3.01 mm) was showed (D: magnified 180˚ reverse image in small box). A prompt endovascular treatment was done and complete obliteration (white arrow) of AR was done (E: magnified DSA working image in small box).

Fig. 2.

A 48-year-old woman patient (Hunt- Hess grade II) with subarachnoid hemorrhage (Fisher grade III). Three-dimensional reconstruction image in initial digital subtraction angiography (DSA) showed a ruptured 8 mm sized aneurysm (white circle) with anteroposteriorly projecting bilobar figure and it`s neck was incorporated with lateral lenticulostriate artery (LSA) on left middle cerebral artery trunk (A: magnified DSA image in small box). Immediate postoperative three-dimensional -DSA demonstrated 0.6 mm x 3.2 mm sized remnant aneurysm (AR, white arrow) was located between LSA and a clipped posterior portion aneurysm (AR, white arrow) (B: magnified DSA image in small box). In follow-up three-dimensional -DSA at postoperative day 30, a rapid regrowth of AR (white arrow) with one bleb, superiorly projecting and depth: 7.10 mm×width: 3.48 mm×neck: 3.21 mm was showed (C: magnified DSA image in small box). A prompt endovascular treatment was done and complete obliteration (white arrow) of AR was done (D: magnified DSA working image in small box). At 3 months follow-up, DSA studies demonstrated complete obliteration of aneurysm.