gms | German Medical Science

Objective: Aneurysms with multiple sacs account for approximately 30% of unruptured intracranial aneurysms (UIAs), but data on their particular treatment are rare. We therefore analyzed patients that underwent microsurgical clipping of these morphologically complex aneurysms at our center.

Methods: All patients that received elective surgical aneurysm repair between January 2010 and September 2017 were retrospectively reviewed. Lobulated aneurysms and aneurysms with daughter sacs were identified, based on two- and three-dimensional angiograms. We analyzed aneurysm location and size, treatment-related complications as well as functional and angiographic outcome. A modified Rankin scale (mRS) score ≤ 2 was defined as favourable outcome. Quantitative variables were expressed with descriptive statistics and categoric variables were expressed as frequencies and percentages.

Results: We identified 47 patients that underwent 49 clipping procedures for 29 lobulated aneurysms and 21 aneurysms with daughter sacs. The median patient age was 51 years (range: 26-69 years). Aneurysms were located at the middle cerebral artery: 39 (78%), anterior communicating artery: 8 (16%), posterior communicating artery: 2 (4%) and internal carotid artery 1 (2%). The mean aneurysm size was 7.2 ± 3.1 mm and 40 aneurysms (80%) were wide-necked (dome-to-neck ratio ≤ 2). All clipping procedures were technically feasible. Favourable outcome was achieved in 91.8% at discharge and 95.7% at last follow-up (median: 11.0 months). The most common complications were seizures: 9 (18.4%), followed by cerebral ischemias: 3 (6.1%), chronic subdural hematomas: 3 (6.1%) and aneurysm ruptures: 2 (4.1%).Treatment-related morbidity was transient in 13 patients (27.7%) and permanent in 5 (10.2%).Among 37 aneurysms available for angiographic follow-up, all aneurysms showed complete occlusion.

Conclusion: Microsurgical clipping of UIAs with multiple sacs is associated with high occlusion rates and long-term morbidity is low. To minimize treatment-specific complications, accurate depiction of aneurysm morphology before surgery and meticulous clip placement are mandatory for these complex aneurysms.