Simultaneous Microsurgical Clipping of Bilateral Intracranial Aneurysms

Intracranial aneurysms (IAs) affect approximately 3%-6% of adults, and up to one third of these patients have multiple IAs, which are associated with an increased risk of rupture.^1-8 Treatment of multiple IAs is dictated by patient and aneurysm characteristics as well as surgical efficiency, when feasible. In this video, we demonstrate the technical nuances of a case involving simultaneous clipping of bilateral IAs. A 70-year-old woman with a history of hypertension was found to have a 6.3-mm, narrow-necked right posterior communicating artery (PCOM) IA and a 5.4-mm, multilobulated, wide-necked left A1 IA on work-up for tinnitus. Treatment of both IAs was recommended on multidisciplinary review, with open (clipping of both aneurysms through a single craniotomy with laterality determined by accessibility of the contralateral IA), endovascular (multistaged transcirculation stent coiling of the left A1 aneurysm followed by coiling of the right PCOM aneurysm), and hybrid (staged clipping of the left A1 aneurysm through a left craniotomy followed by coiling of the right PCOM aneurysm) options discussed. A single-stage open, right-sided approach was selected given the unfavorable contralateral approach to the right PCOM aneurysm and favorable approach to the left A1 aneurysm. This minimized the number of treatment and follow-up procedures and was completed uneventfully. Postoperative imaging demonstrated complete occlusion of both IAs and no adverse sequelae of treatment. Properly selected patients with surgically accessible bilateral IAs, particularly involving wide necks, may benefit from single-stage open clipping procedures, thus avoiding the need for multiple procedures and ongoing dual antiplatelet therapy.