Introduction

The most definitive treatment for intracranial aneurysms is surgical clipping. Recently, endovascular obliteration of aneurysms with platinum alloy coils delivered during angiography by microcatheters has been developed. This technique is less invasive than open surgery and may be appropriate for certain aneurysms, and in patients with severe medical conditions. The decision to use endovascular vs. open surgical techniques is made at Mount Sinai by our multidisciplinary team, consisting of an interventional neuroradiologist, a cerebrovascular neurosurgeon, and a cerebrovascular neurologist.

Presentation

A 71-year-old hypertensive female presented to the Mount Sinai Emergency department with a grade IV subarachnoid hemorrhage, deeply obtunded and with a left hemiparesis.

A CT scan demonstrated a large subarachnoid hemorrhage. Initial resuscitation included endotracheal intubation. She was admitted to the Mount Sinai Neuroscience Intensive Care Unit for placement of a right frontal ventriculostomy.

Angiography demonstrated aneurysms of the right middle cerebral artery (Figure 1), and left posterior communicating artery (PCOMM, Figure 2). Arteriosclerotic narrowing of the internal carotid artery was also noted (Figure 2).

Hospital Course

Due to her age and the severity of her neurological deficit, endovascular treatment was chosen for the MCA aneurysm, and she underwent placement of coils at the time of her initial diagnostic angiogram, again by John Gurian, M.D. Figure 3 demonstrates the placement of coils directly into the aneurysm. Because of the proximal arteriosclerotic narrowing and the funnel-shaped configuration of the left-sided aneurysm, open surgical treatment was chosen for this lesion. Surgery was performed immediately following angiography by Joshua Bederson, M.D., and consisted of a small craniotomy for direct clipping of the aneurysm.

Postoperative Course

The patient tolerated the endovascular and open surgical procedures well and made a rapid recovery to her preoperative baseline status. Postoperative angiography demonstrated complete obliteration of the aneurysm (Figure 4). She subsequently developed cerebal vasospasm requiring hypervolemic hypertensive therapy, and was ultimately discharged to the rehabilitation service.

Discussion

This patient was frail and elderly with severe neurological deficits. Her bilateral aneurysms could not conveniently be clipped surgically at the same sitting, making her an excellent candidate for endovascular treatment. On the other hand, the proximal atherosclerotic narrowing and the configuration of the left-sided aneurysm favored open surgical treatment. The staged multidisciplinary approach provided this patient with the best option for each lesion.

Further References

• Bederson, JB, Editor. Subarachnoid Hemorrhage: Pathophysiology and Treatment. Neurosurgical Topics, American Association of Neurological Surgeons, Park Ridge, Illinois, 1996.