Treatment of complex intracranial aneurysms of anterior circulation using multiple clips

To evaluate the efficacy of multiple clip application for the occlusion of complex intracranial aneurysms, analyzing the technique and outcome of big and giant cerebral aneurysms clipped in our institution.

A total of 259 giant and large intracranial aneurysms (65 ruptured and 193 unruptured) were treated at Fujita Health University Hospital by clipping from January 1975 till December 2008. All patients were treated by multiple clipping according to our multiple clipping technique with reconstruction of the parent vessel. All patients underwent preoperative 3D computed tomography and some patients in addition received digital subtraction angiography. We examined the patients' clinical records and pre- and postoperative case notes, diagnostic and intraoperative images. There were 97 (giant 43, big 54) ICA aneurysms, 105 (giant 45, big 60) MC aneurysms and 32 (giant 7, big 25) AC aneurysms, 25 (giant 14, big 11) VB aneurysms. All patients underwent thorough pre-surgical planning of approach and clipping technique.Surgical technique involved the use of multiple clips with the initial clip securing the deepest neck part and the others successively occluding the rest by remnant clips, occluding along the best plane of neck obliteration.

Out of 193 cases, 165 cases were without any complications. Temporary complications were seen in 18 cases and permanent in 10. In our 65 ruptured aneurysms operated on, outcome was in line with standard outcome according to the SAH grade on admission (H&H, WFNS grade). In total, 183 cases had good results (94.8%).

The "multi" clip method for the treatment of complex intracranial aneurysms can be a safe and effective method where a single clip cannot obtain complete neck closure. Proper preoperative understanding of the three-dimensional anatomy of the aneurysm and appropriate preoperative planning and selection of suitable clipping method, using an appropriate combination of clips, definitely can reduce the morbidity and mortality in these patients.