Frontal craniotomy for a complex pericallosal aneurysm
Simone E. Dekker, MD, University Hospitals Case Medical Center, Cleveland, OH Kevin K. Yoo, BA, Lewis Katz School of Medicine, Philadelphia, PA Wenceslas Krakowiecki, BS, Case Western Reserve University School of Medicine, Cleveland, OH Nicholas C. Bambakidis, MD, University Hospitals Case Medical Center, Cleveland, OH
This case illustrates issues in the clipping for a complex pericallosal aneurysm 70 female.
Patient is a 70 female with recent history of shingles infection of the eye, seizure, and encephalitis. An incidental 7 x 3.9mm pericallosal aneurysm was found.
Interhemispheric right-sided approach
Conservative medical management with serial observation Interventional radiology for coiling
Select from one of the following, if appropriate Supine/Flat Turning Neurtral
Right frontal craniotomy using stereotactic navigation interhemispheric right-sided dissection was then carried out using the operating microscope exposing the interior cerebral artery complex, pericallosal artery, callosal marginal. A large wide neck multilobulated partial atherosclerotic aneurysm was then encountered. Intermittent temporary clip occlusion utilized to clip reconstruct the ACA bifurcation completely occluding the aneurysm with excellent flow in the proximal and distal ACA branches confirmed with ICG video angiography and microvascular Doppler. The wound was then copiously irrigated. Hemostasis was excellent. Dura was loosely approximated with synthetic dural graft. The bone was replaced using titanium plates and screws. The scalp and galea were closed using sutures and staples. There were no complications.
A repeat scan of her head was stable. An EEG, performed because of a fluctuating neurological exam, demonstrated focal status in her right frontal region. She was started on keppra 1 g BID. Epilepsy service was consulted, and they recommend a 750mg of Keppra in the AM and 1000mg Keppra in PM. Discharged to rehab on POD 10. Motor strength 5/5 Mild aphasia
At 6 week follow up patient is doing well, reporting no seizures but only mild short term memory loss. Patient is scheduled for epilepsy neurology follow up and will continue taking keppra.
Pearls and Pitfalls
For distal ACA aneurysms approached through an interhemispheric craniotomy, care must be taken as proximal control is difficult to obtain early in the dissection Stereotactic navigation can be helpful in guiding dissection to the aneurysm Positioning of the patient in lateral position can also be considered
In a study of 37 patients undergoing clipping of either ruptured or unruptured aneurysms it was found that while patients that underwent elective clipping of unruptured aneurysms had mild cognitive dysfunction 3 months post op. This dysfunction was resolved however after 12 months.1 This same study compared the ability to return to work in patients with ruptured and unruptured aneurysms. They found that all patients with unruptured aneurysms were able to return to work within a year in contrast to only 60% of patients with a ruptured aneurysm.1