The patient came to the clinic 16-April-2013 complaining of headache for 3 years associated with nausea. The patient underwent left eye surgery for visual disturbances 18 months ago without improvement. MRI of the brain done 09-April-2013 showing a huge mass in the left suprasellar region mostly an aneurysm of the left supraclinoid with bad quality MRA, as be the aneurysm involving the left supraclinoid, left A1 and M1.

On examination: The patient is neurologically free. She is right handed and have temporal anopia left visual field. Considering that the performed pictures showing an aneurysm with high mortality rate and the good condition of the patient, it was advised to repeat MRI of better quality and if the aneurysm of the same description to put the patient in the wait for progression.

The patient was sent for new MRI which showed the same aneurysm with good neck  originating just proximal to the bifurcation of supraclinoid to A1 and M1 distal to the origin of the anterior choroidal artery. There are scattered lacunar infarcts in the vicinity of both cerebral hemispheres.

The patient was admitted to Jordan hospital and angiography done 18-April-2013 with attempt for embolization, which was not performed due wide neck of the aneurysm. Cross circulation is absent from the right ICA.

Bifrontal approach with left pterional modification. The bone flap reflected to the left ear. The frontal sinus was violated to obtain an approach flush to the base. The left olfactory tract was bisected and the left sylvian cistern was opened. The arachnoid surrounding the left nerve was dissected to gain better visualization of the left supraclinoid. The aneurysm was seen fulfilling all sellar cavity pushing the left optic nerve up. The neck of the aneurysm was not only wide, but the supraclinoid was actually part of the lateral wall of the aneurysm. It was possible to see the proximal part of the supraclinoid before the neck and the distal part after the neck and the A1 and M1 segments. They were full of calcification. An angled with long blade of Yasargil Ausculap clip was applied, so as to create a lumen to the artery from the lateral wall of the giant aneurysm. After applying the clip, the created artery is small in diameter and narrow. Another clip was applied more medial to the first, away from the created artery and the first clip was removed. The shape of the artery regained an acceptable diameter. The cavity of the closed aneurysm was evacuated by insulin syringe, the with 20 ml syringe. The aneurysm collapsed and sellar cavity became empty, but the wall of the aneurysm was adherent to the left optic nerve. They were left untouched. After evacuation of the aneurysm, it was possible to see the running under the PcoA and the AchA left side.

Routine closure of the wound. Smooth postoperative recovery.

The aneurysm is calcified and application of clip is full of hazard to fracture of the wall. For this reason, 2 clip applications were limited to have the best possible result.

For more information about treating giant aneurysms please click here and here!