Intraoperative Adjuncts for the Unusual Internal Carotid Artery Aneurysms

We present 3 patients with unusual internal carotid artery (ICA) aneurysms who underwent neck clipping with various intraoperative adjuncts. Case 1. A 64-year-old female underwent surgery of a large intracavernous ICA aneurysm because it enlarged significantly after 4 years of observation. Suction decompression via the catheter for intraoperative angiography was quite effective to dissect and clip the large aneurysm in the cavernous sinus. Case 2. A 74-year-old male with a re-grown aneurysm on the anterior wall of the ICA. The ruptured aneurysm had initially been clipped 3 years before. The follow-up angiography revealed that a slight neck remnant became prominent. A balloon test occlusion resulted in no neurological deficits. Because of the severe adhesion between the frontal lobe and aneurysm with the previous clips, we dissected the aneurysm and clips subpially from the brain. Then during the temporary trapping of the ICA, clips were applied parallel to the ICA, catching the normal wall of the ICA under the enlarged monitoring view of the endoscope. Case 3. A 41-year-old female with an angiographically occult ruptured aneurysm at the ICA-posterior communicating artery (PcomA). The aneurysm reruptured during the surgery on the ipsilateral unruptured carotid cave aneurysm that had been supposed as the ruptured aneurysm before surgery. The aneurysm was blind under the microscope because the aneurysm was tiny and located posteriorly. Therefore, the aneurysm was clipped by catching the intact wall of the ICA and PComA beyond the lesion under the simultaneous monitoring of microscope and endoscope. None of the 3 cases showed postoperative morbidity. In conclusion, we should anticipate all intraoperative problems in treating cerebral aneurysms and prepare all adjuncts for surgery previously.