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(A) Initial computed tomography showed diffused subarachnoid hemorrhage. (B) Three-dimensional rotational angiography revealed a large saccular aneurysm. The dome and neck size of the aneurysm were 17 and 7 mm, respectively.
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Initial computed tomography revealed diffused subarachnoid hemorrhage (WFNS [World Federation of Neurosurgical Societies] score: 1; Hunt and Hess score: 2) (Fig. 1A). ICA (Fig. 1B). In consideration of the location, size, and shape of the aneurysm, endovascular treatment was planned as the initial treatment.
(A) Anteroposterior angiographic views before coiling. (B) Anteroposterior angiographic views after coiling present near complete occlusion.
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The aneurysm was completely occluded with 22 bare platinum coils (Fig. 2A, B).
Goldman visual field examination demonstrated a central scotoma in the right eye and left superior quadrantanopsia in the left eye, and in both, visual acuity was decreased.
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Visual field test at 4 weeks after the coil embolization revealed a right central scotoma and a left superior temporal quadrantanopsia, and both visual acuity was decreased, especially in the right eye (right vision [RV] = 30 cm/f.c., left vision [LV] = 20/32) (Fig. 3).
Axial T2-weighted magnetic resonance imaging showing mass effect on the optic chiasma, and perianeurysmal brain edema was not found apparently.
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Perianeurysmal brain edema of the T2-weighted images was not recognized apparently (Fig. 4).
Three-dimensional rotational angiography 11 weeks after coiling showed complete embolization of the aneurysm.
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At 11 weeks after the coil embolization, we confirmed complete obliteration of the aneurysm and patency of the ophthalmic artery by follow-up DSA (Fig. 5).
The operative findings. (A) After optic canal was unroofed, anterior clinoid process was removed and the distal carotid dural ring was opened. a, Internal carotid artery (ICA); b, optic nerve; c, aneurysm; d, suction device. (B) Embolized coils were cut into small pieces and removed with a suction probe inside the aneurysmal dome. e, ICA; f, aneurysmal dome; g, coils; h, microscissors; i, suction device. (C) Neck clipping was performed using two fenestrated clips. j, Optic nerve; k, ICA; l, fenestrated clips; m, suction device.
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We performed neck clipping of the aneurysm with optic canal unroofing, anterior clinoidectomy, and partial removal of the previously embolized coils (Fig. 6).
Visual fields demonstrate marked improvement in both eyes 1 month after surgery.
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Visual field test at 1 month after the direct surgery demonstrated marked improvement (RV = 20/200; LV = 20/25) (Fig. 7).
Three-dimensional rotational angiography 3 months after surgery showed compete obliteration of the aneurysm.
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At 3 months after clipping, we confirmed complete obliteration of the aneurysm by follow-up DSA (Fig. 8).