PMC5735435_01
(a and b) Preoperative CT scan and MR imaging showing a giant thrombosed DACA aneurysm with calcified wall and perifocal edema in the right frontal lobe. (c) The oblique view of preoperative 3-dimensional MR angiography demonstrating a 6 cm giant thrombosed aneurysm at the left A2-A3 junction. The left PcaA (short arrow) and CmaA (long arrow) originated from the aneurysmal neck. A non-thrombosed area was present within the near-neck aneurysmal sac (arrowhead)
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F1
Noncontrast computed tomography (CT) scan and magnetic resonance (MR) imaging of the head revealed a giant thrombosed DACA aneurysm with thickened calcified walls and significant perifocal edema in the right frontal lobe [Figure 1a and b]. Three-dimensional MR angiography demonstrated that a thrombosed aneurysm with a maximum diameter of 6 cm was located at the left A2-A3 junction [Figure 1c].
Illustrations of the sequentially shifting clipping technique following intra-aneurysmal thrombectomy. (a) The interhemispheric approach exposed the left A2, PcaA (short arrow), and CmaA (long arrow). The near-neck space (surrounded by a dotted line) was non-thrombosed. (b) A bayonet-shaped clip was applied to the neck, but slipped onto the left A2. (c) The aneurysmal wall was incised and the intra-aneurysmal thrombus was evacuated using CUSA. (d) Once adequate pliability and flexibility of the neck for clipping was obtained, the second clip was added parallel to and adjacent to the aneurysm side of the first clip. (e) The first clip was removed. The blood flow of the left PcaA significantly improved, but that of the left CmaA was still poor. (f) In the same way as in D), the third clip was applied. (g) The second clip was removed. The blood flow of the left CmaA became sufficient. The complete obliteration of the aneurysm was also accomplished
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F2
This sequential, progressive clipping technique following intra-aneurysmal thrombectomy is illustrated in Figure 2.
(a, b) Postoperative CT scan and MR imaging showing no residual aneurysm and resolution of the right frontal edema. (c) Postoperative 3-dimentional digital subtraction angiogram demonstrating complete neck clipping of the aneurysm with preservation of all branches (PcaA, short arrow; CmaA, long arrow)
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F3
Postoperative CT scan and MR imaging demonstrated no residual aneurysm and resolution of the right frontal edema [Figure 3a and b]. A postoperative digital subtraction angiogram showed complete neck clipping of the aneurysm with preservation of all branches [Figure 3c].