Successful Clipping of a Large Fusiform Aneurysm in the Basilar Artery Using an Endovascular Technique: Report of a Subarachnoid Hemorrhage Case

Abstract

An 80-year-old male presented with a subarachnoid hemorrhage of Hunt and Kosnik Grade IV. Cerebral angiography revealed a large eccentric fusiform aneurysm arising from the lower portion of the basilar artery just distal to the right anterior inferior cerebellar artery. We decided to surgically treat the ruptured basilar artery aneurysm in the acute stage via a right retromastoid suboccipital approach. Before the operation, we guided a balloon catheter into the left vertebral and right carotid arteries. Intraoperatively, we applied a temporary clip to the right vertebral artery. After exposing the aneurysm, we temporarily inflated the occlusion balloon within the left vertebral and right internal carotid arteries. After suction decompression from the left vertebral artery, we used Sugita’s long clip to clip the neck parallel to the basilar trunk. Bradycardia occurred, but the heart rhythm recovered immediately after the recanalization of these arteries. Intraoperative digital subtraction angiography showed obliteration of the aneurysm and preservation of basilar artery patency. The patient gradually recovered consciousness after being in a comatose state for 10 hours after surgery. It is possible to directly clip a large basilar trunk aneurysm. The clipping tends to be done in the same direction as the operative approach. Therefore, the operative approach should be parallel to and should preserve the basilar artery. The intraoperative endovascular technique (using temporary balloon occlusion) and intraoperative digital subtraction angiography can contribute to gaining proximal artery control and verifying basilar artery patency. Clipping is much easier when using suction decompression. However, temporary balloon occlusion should be done as quickly as possible.