A technique for sequential, progressive clipping for a giant thrombosed distal anterior cerebral artery aneurysm: Technical note

BACKGROUND: Giant thrombosed aneurysms often present with thickened walls and a hard thrombus, including in the near-neck aneurysmal sac. These usually make it difficult to achieve complete neck clipping with preservation of local branch patency. Here, we demonstrate a simple but safe and effective technique to overcome these problems in a patient with a 6-cm giant thrombosed distal anterior cerebral artery aneurysm. CASE DESCRIPTION: A 77-year-old-man suffered from loss of volitional activity due to the frontal mass effect. The aneurysm was exposed with unilateral paramedian craniotomy and an interhemispheric approach. The clip was applied to the aneurysmal neck but it slipped onto the parent artery, which caused branch artery occlusion. Intra-aneurysmal thrombectomy was immediately performed near the aneurysmal neck with ultrasonic aspiration. The next clip was added along the aneurysm side of the preceding clip, which was then removed. This procedure was repeated twice so that complete neck clipping was achieved while preserving the branch patency. All the residual thrombus and aneurysmal wall were subsequently removed. Postoperatively, there was no additional neurological deficit. The patient's mental function was significantly improved. CONCLUSIONS: We conclude that the sequential, progressive clipping technique is a robust option for successful neck clipping of giant thrombosed aneurysms.