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Case of the Month - August  2017

68-year-old male patient with high intensity headache. Simple head CT scan with FISHER IV subarachnoid hemorrhage with intraparenchymal right temporal hematoma. Panangiography shows a ruptured right middle cerebral artery bifurcation aneurysm.

The patient is taken for drainage of the hematoma and subsequent clipping of the aneurysm. It is necessary to perform the procedure with 2 clips due to persistence of flow verified with intraoperative Micro Doppler after the placement of the initial clip. 

Cerebral anerusimas

Edgar G. Ordoñez-Rubiano, MD, Edgar G. Ordóñez-Mora, MD, IFAANS

Intracranial aneurymes


An aneurysm is a dilation of a blood vessel. Most intracranial aneurysms (LAs) have a saccular shape. ( 1 ) In turn, saccular aneurysms are abnormal focal herniations of the cerebral arteries that cause high rates of morbidity and mortality. ( 2 )




In the adult population, the international prevalence of intracranial aneurysms is between 1 and 5%  ( 1-3 ), which would approximate an estimated 1 to 2 million people in Colombia.  Although there are no studies on the prevalence and incidence of this pathology, it is known that the population in Colombia that suffers from cerebrovascular disease is approximately 46.1 per 1,000 inhabitants. ( 4 )



The estimated incidence of spontaneous subarachnoid hemorrhage (SAH) or aneurysm in the United States is 1 case per 10,000 people ( 5 ) and has a mortality rate of 45% at 30 days. An estimated 30% of patients who survive have some type of disability (moderate to severe). ( 2 ) About 30% of patients with SAH develop arterial vaso-spasm, which further worsens the prognosis of these patients. ( 6 )


Handling options

There are 3 options for the treatment of intracranial aneurysms: observation ( 2 ), craniotomy with clipping of the aneurysm  ( 7 , 8 ) and endovascular occlusion with the use of controlled release coils (“coiling” in English).  ( 7 , 9-12 )


Risks in handling

In a series from one center ( 13 ) and in 2 meta-analyzes ( 14 , 15 ) the morbidity and mortality rates associated with clipping of unruptured aneurysms ranged between 4.0 and 10.9% and between 1.0 to 3.0% respectively. A satisfactory clipping is generally associated with protection against rupture, however some studies have shown a low risk of error in the surgical technique such as incomplete occlusion (in 5.2%) ( 16 ), recurrence (1,5 %) and bleeding (0.26%).  ( 17 )

On the other hand, the most important risks of endovascular management include arterial dissection (0.7%), arterial occlusion (2%), and thrombo-embolic phenomena (2.4%).  ( 2 , 18 ) Other risks include reactions to contrast dye, infections, pseudoaneurimas, and bruising in the groin.  ( 18 )



Until 1974, when Serbilnenko described the first endovascular occlusion of a brain aneurysm in Moscow,  ( 19 ) microvascular clipping was the only surgical approach for intracranial aneurysms. However, after the introduction of Gluglielmi release coils in 1991 the number of patients who are taken for endovascular coiling has continued to increase.  ( 20 )


However, despite efforts to find the treatment of choice, the treatment of intracranial aneurysms remains controversial. Microvascular neurosurgery, interventional neuroradiology, and neurological critical care specialists must decide the best management option for each individual patient.  



one.          Weir B. Unruptured intracranial aneurysms: a review. Journal of neurosurgery. 2002; 96 (1): 3-42. Epub 2002/01/17.

two.          Brisman JL, Song JK, Newell DW. Cerebral aneurysms. The New England journal of medicine. 2006; 355 (9): 928-39. Epub 2006/09/01.

3.          Lai HP, Cheng KM, Yu SC, Au Yeung KM, Cheung YL, Chan CM, et al. Size, location, and multiplicity of ruptured intracranial aneurysms in the Hong Kong Chinese population with subarachnoid haemorrhage. Hong Kong medical journal = Xianggang yi xue za zhi / Hong Kong Academy of Medicine. 2009; 15 (4): 262-6. Epub 2009/08/05.

Four.          Pradilla GA VB, Leon-Sarmiento FE, GENECO group. Colombian national neuroepidemiological study (EPINEURO). Rev Panam Salud Publica / Pan AM J Public Health. 2003; 14 (2): 104-11.

5.          Wijdicks EF, Kallmes DF, Manno EM, Fulgham JR, Piepgras DG. Subarachnoid hemorrhage: neurointensive care and aneurysm repair. Mayo Clinic proceedings Mayo Clinic. 2005; 80 (4): 550-9. Epub 2005/04/12.

6.          Mejía JA, Niño de Mejía M, Ferrer LE, Cohen D. Cerebral vasospasm secondary to subarachnoid hemorrhage due to ruptured intracerebral aneurysm. . Rev Col Anest. 2007; 35 (2): 143-62.

7.          Guresir E, Schuss P, Berkefeld J, Vatter H, Seifert V. Treatment results for complex middle cerebral artery aneurysms. A prospective single-center series. Acta neurochirurgica. 2011; 153 (6): 1247-52. Epub 2011/04/14.

8.          van Dijk JM, Groen RJ, Ter Laan M, Jeltema JR, Mooij JJ, Metzemaekers JD. Surgical clipping as the preferred treatment for aneurysms of the middle cerebral artery. Acta neurochirurgica. 2011; 153 (11): 2111-7. Epub 2011/09/08.

9.          Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005; 366 (9488): 809-17. Epub 2005/09/06.

10.        Eskridge JM, Song JK. Endovascular embolization of 150 basilar tip aneurysms with Guglielmi detachable coils: results of the Food and Drug Administration multicenter clinical trial. Journal of neurosurgery. 1998; 89 (1): 81-6. Epub 1998/07/01.

eleven.        Pierot L, Barbe C, Spelle L. Endovascular treatment of very small unruptured aneurysms: rate of procedural complications, clinical outcome, and anatomical results. Stroke; a journal of cerebral circulation. 2010; 41 (12): 2855-9. Epub 2010/10/30.

12.        Suh SH, Kim DJ, Kim DI, Kim BM, Chung TS, Hong CK, et al. Management of anterior inferior cerebellar artery aneurysms: endovascular treatment and clinical outcome. AJNR American journal of neuroradiology. 2011; 32 (1): 159-64. Epub 2010/11/06.

13.        Solomon RA, Fink ME, Pile-Spellman J. Surgical management of unruptured intracranial aneurysms. Journal of neurosurgery. 1994; 80 (3): 440-6. Epub 1994/03/01.

14.        Raaymakers TW, Rinkel GJ, Limburg M, Algra A. Mortality and morbidity of surgery for unruptured intracranial aneurysms: a meta-analysis. Stroke; a journal of cerebral circulation. 1998; 29 (8): 1531-8. Epub 1998/08/26.

fifteen.        King JT, Jr., Berlin JA, Flamm ES. Morbidity and mortality from elective surgery for asymptomatic, unruptured, intracranial aneurysms: a meta-analysis. Journal of neurosurgery. 1994; 81 (6): 837-42. Epub 1994/12/01.

16.        Thornton J, Bashir Q, Aletich VA, Debrun GM, Ausman JI, Charbel FT. What percentage of surgically clipped intracranial aneurysms have residual necks? Neurosurgery. 2000; 46 (6): 1294-8; discussion 8-300. Epub 2000/06/02.

17.        David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. Journal of neurosurgery. 1999; 91 (3): 396-401. Epub 1999/09/02.

18.        Murayama Y, Nien YL, Duckwiler G, Gobin YP, Jahan R, Frazee J, et al. Guglielmi detachable coil embolization of cerebral aneurysms: 11 years' experience. Journal of neurosurgery. 2003; 98 (5): 959-66. Epub 2003/05/15.

19.        Serbinenko FA. Balloon catheterization and occlusion of major cerebral vessels. Journal of neurosurgery. 1974; 41 (2): 125-45. Epub 1974/08/01.

twenty.        Romani R, Lehto H, Laakso A, Horcajadas A, Kivisaari R, von und zu Fraunberg M, et al. Microsurgery for previously coiled aneurysms: experience with 81 patients. Neurosurgery. 2011; 68 (1): 140-53; discussion 53-4. Epub 2010/12/15.

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