Introduction
The most definitive treatment for intracranial aneurysms is surgical clipping. In most cases this requires a small frontotemporal craniotomy. Although this is tolerated well by most patients, reducing the size of the opening would be beneficial.
Recent advances in technique and instrumentation permit certain intracranial aneurysms to be treated using very small openings. These so-called keyhole openings are not appropriate for every aneurysm, but selected patients can benefit from this innovative approach.
History
This 48-year-old family practitioner from Barbados was in her normal state of health, which included hypertension, when she developed a severe headache. This headache persisted, but she did not seek medical care for several days.
She presented for medical evaluation to David Corbin, M.D.,
Neurologist in the Department of Medicine, Queen Elizabeth Hospital,
Barbados.
A CT scan demonstrated a large left frontal intraparenchymal hemorrhage with mass affect. She was transferred to the Clinical Program for Cerebrovascular Disorders at The Mount Sinai Hospital for further evaluation.
Physical Examination
On admission, the patient had a mild right facial droop and question of slow speech, but was otherwise neurologically intact.
Diagnostic Procedures
A repeat CAT scan and MRI scan demonstrated a large intraparenchymal hemorrhage that was not characteristic of a hypertensive bleed. Angiography demonstrated an incidental aneurysm of the right anterior choroidal artery, approximately 6 mm in diameter (Figure 1). No other pathology that might explain her hemorrhage was identified.
Hospital Course
The facial droop resolved over several days. She was discharged to home for a period of recovery, and readmitted six weeks later for a second angiogram and elective clipping of the anterior choroidal aneurysm. The second angiogram did not reveal any lesion in the region of her prior bleed, and the aneurysm was unchanged in appearance.
Surgical Procedure
Surgery was performed by Joshua Bederson, M.D., and Wesley King, M.D. A small supraorbital incision provided access, and the aneurysm was clipped with endoscopic assistance. Figure 2 is an Intraoperative photograph showing the right supraorbital exposure. The aneurysm was secured uneventfully.
Postoperative Course
The patient tolerated the surgical procedure well and made a rapid postoperative recovery. Postoperative angiography demonstrated complete obliteration of the aneurysm (Figure 3), and the patient was discharged from the hospital on the third postoperative day. She has returned to work as a physician in Barbados.
Discussion
This patient had a small incidental aneurysm that was ideally suited for a minimally invasive approach. It is probable that the magnitude of her procedure and its impact on her were lessened by the use of this technique. Although not suitable for the majority of patients, in selected cases minimally invasive techniques and endoscopic assistance should be considered.
Further References
Bederson JB et al. Recommendations for the management of patients with unruptured intracranial aneurysms: A Statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 2000 Nov;31(11):2742-50.
|
