J Cerebrovasc Endovasc Neurosurg.  2016 Sep;18(3):281-285. 10.7461/jcen.2016.18.3.281.

Incomplete Clipping Resulting from Scissoring of the Clip Blades during Treatment of a Large Atheromatous Aneurysm

• Kim JS
• Lee SH
• Ko HC
• Shin HS
• Koh JS

• KMID: 2355655
• DOI: http://doi.org/10.7461/jcen.2016.18.3.281

Abstract

The cerebral aneurysm 'clip scissoring' phenomenon resulting from clip blade twisting is an unpredictable surgical complication. Additionally, incomplete clipping resulting from the presence of an atherosclerotic wall in the neck of the aneurysm can also cause unforeseen problems. Here, the authors present an unusual case of incomplete clipping of a large, atheromatous aneurysm resulting from clip scissoring, which was treated with additional endovascular coiling.

Keyword

Intracranial aneurysm; Atheroma; Surgical clip; Treatment failure

MeSH Terms

Aneurysm*
Intracranial Aneurysm
Neck
Plaque, Atherosclerotic
Surgical Instruments
Treatment Failure

Figure

• 

  Fig. 1 T2-weighted coronal magnetic resonance imaging (MRI) (A) and magnetic resonance angiography (MRA) (B) performed during a health-screening test demonstrating a large, unruptured middle cerebral artery aneurysm. Reconstruction of 3D rotational angiogram with the anterioposterior (C), and lateral (D) view, and translucent 3D rotational image (E) providing more detailed structural information including the precise size of the aneurysm.

• 

  Fig. 2 Intraoperative photographs during neck clipping surgery showing the right middle cerebral artery aneurysm before (A) and after (B) clipping using a 20 mm straight clip. Note that atherosclerotic changes (asterisk) encompassing the parent artery, aneurysm neck, and extending further into the aneurysm sac. Clip blades seem to be closed without any perceivable distortion as viewed from the operative field.

• 

  Fig. 3 Post-operative 3-dimensional computed tomography angiogram (3D-CTA) revealing significant filling of the aneurysm (A, B). Subsequent cerebral 3D rotational angiography (C, D and E) showing scissoring of the clip blade onto the aneurysm neck and incomplete clip closure, which allowing the aneurysm to be filled with blood.

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  Fig. 4 Neurointerventional image during coil embolization showing the microcatheter barely entering the aneurysm (A). Post-treatment non-subtracted angiogram showing no contrast filling of the aneurysm (B, C).

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  Fig. 5 Illustrations showing the scissoring of the clip and incomplete clipping resulting from the presence of an atherosclerotic wall in the neck of the aneurysm. (A) Lateral view of the aneurysm containing atheroma within the neck. (B) Axial view severed just above the neck of the aneurysm. (C) When the neck of the aneurysm is clipped with a long clip made of titanium, scissoring phenomenon may occur due to interference of atheroma. (D) Axial view of incomplete closure of the clip blade resulting from irregularly distributed atheroma within the neck. Note that blood flow is still maintained through remaining neck of the aneurysm.

Reference

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