**12. Our experience**

During many years of practice, we learned that trying to make an asymptomatic patient feel better is ridiculously challenging. As for the patients themselves, the notion of living with an "undetonated bomb" might be daunting. As we have already shown, the issue of UIAs in a patient harboring multiple aneurysms out of which one has bled is equally controversial in the contemporary scientific literature.

We reviewed the experience of a single neurosurgeon (Professor Ioan Ștefan Florian MD, PhD—Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania) in microsurgical clipping over 21 years (1997–2017). This amounted to a consecutive series of 872 patients with intracranial aneurysms (1004 separate lesions in total), both ruptured and unruptured.

From this patient pool, 89 (10.2%) presented with solitary UIA, the ages at the two extremes being 11 and 86 years, respectively. Among these, 46 (51.69%) were admitted with Hunt and Hess grade 0, while the remaining 43 (48.31%) were admitted with grade 1a. Regarding clinical outcome, our most important conclusion was that we encountered no mortality in this particular group. Eighty-seven patients (97.8%) were discharged with a Glasgow Outcome Score (GOS) of 5 (**Figure 5**).

**165**

**Figure 7.**

**Figure 5.**

**Figure 6.**

*Preventing Rupture: Clipping of Unruptured Intracranial Aneurysms*

*and Hess grade 0; 1a, Hunt and Hess grade 1a; GOS, Glasgow Outcome Score).*

*cerebral artery; BA, basilar artery; Opht, ophthalmic artery.*

*number of aneurysms in a single patient was six.*

*Outcome of patients with solitary unruptured aneurysms at time of discharge—author's case series (0, Hunt* 

*Location of lesions in the multiple cerebral aneurysms group. MCA, middle cerebral artery; ICA, internal carotid artery; ACoA, anterior communicating artery; PCoA, posterior communicating artery; ACA, anterior* 

*Number of lesions per patient with multiple intracranial aneurysms. The majority of patients with two aneurysms had both lesions on the same side, whereas for three or more lesions, these were bilateral. The highest* 

*DOI: http://dx.doi.org/10.5772/intechopen.88038*

*Preventing Rupture: Clipping of Unruptured Intracranial Aneurysms DOI: http://dx.doi.org/10.5772/intechopen.88038*

#### **Figure 5.**

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

angiographic procedures can confirm proper clip placement.

after aggressive manipulation of the vessels.

remains uncertain.

**12. Our experience**

yet certain aneurysms may require more complex techniques [151, 125, 160].

degeneration [94]. Using a double-clip technique can often prevent this from occurring,

Aneurysmal residue or incomplete occlusion signifies an aneurysm sac or neck that is still permeable and has a significant chance of rupture [37, 80, 86, 161, 162]. Aneurysmal rest (or dog ear) occurs when a small triangular portion of the neck is not occluded by the aneurysmal blades. In time, and under certain hemodynamic conditions, this residual neck can lead to aneurysm regrowth, and eventual rupture, requiring further imaging studies and possibly another intervention [104]. In the microsurgical series described by Nanda, the majority of recurrences were found at the ACoA, followed by ICA, VA, and PICA [163]. Adequate neck dissection and using suitable clips may avoid this complication [164]. Also using intraoperative

Clipping UIAs of the ophthalmic artery can lead to visual disturbances [162]. Apparently, if visual deficit was present before treatment, clipping may offer a higher degree of improvement than coiling [162, 165]. From our own experience, we can add that the clipping of aneurysms of the paraclinoid segment of the ICA or the superior hypophyseal artery may in some cases result in acute pituitary deficiency. Some of these patients will require lifelong hormone substitution therapy. Cerebral vasospasm is predominantly a complication of ruptured aneurysms, but it has rarely been described as occurring after clipping of UIA [166]. The exact etiological mechanism is unknown, although it might be multifactorial, especially

Cognitive dysfunction after UIA therapy may occur, regardless of treatment method [137]. Nevertheless, the exact effect clipping has on cognitive functions

Some patients with surgically treated UIAs may develop a chronic subdural hematoma in time, being at a higher risk for this than patients with ruptured lesions [167]. Risk factors include brain atrophy, male sex, chronic antiplatelet use, and advanced age. As long as the risk of complications remains, the incentive of perfecting microsurgical techniques will persist. The purpose of gaining surgical experience is to ensure a long-term survival of the patient with the best possible neurological outcome, while also striving to lower or eliminate the chance of adverse events.

During many years of practice, we learned that trying to make an asymptomatic patient feel better is ridiculously challenging. As for the patients themselves, the notion of living with an "undetonated bomb" might be daunting. As we have already shown, the issue of UIAs in a patient harboring multiple aneurysms out of which one has bled is equally controversial in the contemporary scientific literature. We reviewed the experience of a single neurosurgeon (Professor Ioan Ștefan Florian MD, PhD—Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania) in microsurgical clipping over 21 years (1997–2017). This amounted to a consecutive series of 872 patients with intracranial aneurysms (1004

From this patient pool, 89 (10.2%) presented with solitary UIA, the ages at the two extremes being 11 and 86 years, respectively. Among these, 46 (51.69%) were admitted with Hunt and Hess grade 0, while the remaining 43 (48.31%) were admitted with grade 1a. Regarding clinical outcome, our most important conclusion was that we encountered no mortality in this particular group. Eighty-seven patients (97.8%) were discharged with a Glasgow Outcome Score (GOS) of 5 (**Figure 5**).

separate lesions in total), both ruptured and unruptured.

**164**

*Outcome of patients with solitary unruptured aneurysms at time of discharge—author's case series (0, Hunt and Hess grade 0; 1a, Hunt and Hess grade 1a; GOS, Glasgow Outcome Score).*

#### **Figure 6.**

*Location of lesions in the multiple cerebral aneurysms group. MCA, middle cerebral artery; ICA, internal carotid artery; ACoA, anterior communicating artery; PCoA, posterior communicating artery; ACA, anterior cerebral artery; BA, basilar artery; Opht, ophthalmic artery.*

#### **Figure 7.**

*Number of lesions per patient with multiple intracranial aneurysms. The majority of patients with two aneurysms had both lesions on the same side, whereas for three or more lesions, these were bilateral. The highest number of aneurysms in a single patient was six.*


#### **Table 1.**

*Comparison between the two groups on admission (Hunt and Hess scale, associated complications, and age) and on discharge (preoperative days, Glasgow Outcome Scale, complications, and mortality).*

In our series, we identified 101 patients (11.58%) with multiple aneurysms, harboring a total of 257 lesions. The most common location was the middle cerebral artery, followed by the internal carotid and anterior communicating artery (**Figure 6**). Initially, our approach in treating them was to clip the ruptured aneurysms or the ones with the higher risk, leaving the others for a later procedure. However, after we lost two patients with MIA on the night before the second planned intervention due to the rupture of the single unclipped lesion, we overhauled our methodology. The current goal in all cases is single-stage surgery (unilateral frontopterional approach) with all aneurysms clipped during the same procedure. If this is unfeasible, we perform a second craniotomy during the same anesthesia, as we believe the process of patient waking elevates the risk of rupture of any unclipped UIA.

Most patients presented with two aneurysms (57.6%). The highest number of aneurysms was six (one patient, female). The male-to-female ratio was 1:3, with the higher number of aneurysms leading to an increase of female predominance. Our series too suggests that MIA is primarily a pathology of the female gender (**Figure 7**).

We analyzed the complication rate, mortality, and state at discharge between groups with unilateral and bilateral aneurysms of the anterior circulation. There were no statistically significant differences between the two groups regarding the rate of complications or the outcome (*P* > 0.05, **Table 1**). When we compared patients with mirror middle cerebral aneurysms to the rest of the lot, no statistically significant difference could be observed either (*P* > 0.05). 60.39% of patients (61) were discharged with a favorable neurological outcome (GOS of 4 or 5).

Our data demonstrates that, with an appropriate selection of cases, surgery yields definitive and favorable results in solitary UIAs if handled by an experienced team. "Single-stage, single-opening surgery" is a viable option for treating the unruptured lesions in the context of multiple intracranial aneurysms.

#### **13. Final remarks and future directions**

Clipping of UIAs remains a valuable treatment option in preventing rupture and subsequent hemorrhagic stroke. In the hands of experienced vascular neurosurgeons, it is still a secure and long-lasting procedure, despite the relative ease and comparable safety and durability of endovascular procedures. Since aneurysmal rupture cannot be accurately predicted, clipping stands as a virtually curative procedure. Nevertheless, being an invasive procedure, it still harbors inherent risks. While our experience shows that clipping of solitary UIAs is not associated with mortality and only minimal morbidity, clipping of MIAs can pose a challenge.

**167**

**Author details**

**Conflict of interest**

**Other declarations**

Romania

and Ioan Stefan Florian1,2

Cluj-Napoca, Romania

Pharmacy, Cluj-Napoca, Romania

provided the original work is properly cited.

Ioan Alexandru Florian1,2\*, Teodora Larisa Timis3

1 Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca,

3 Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Department of Neurosurgery, Iuliu Hatieganu University of Medicine and

\*Address all correspondence to: florian.ioan.alexandru@gmail.com

, Cristina Caterina Aldea1,2

*Preventing Rupture: Clipping of Unruptured Intracranial Aneurysms*

The authors declare that there is no conflict of interest.

All authors contributed equally to the writing of this manuscript.

Because any unclipped lesion bears a significant risk of rupture, we strongly advocate for the treatment of all aneurysms in patients with MIAs in the same procedure, and if feasible, through the same opening. The techniques and instruments themselves require constant updates in order to minimize postoperative morbidity and mortality while also ensuring ease and comfort in use. In the future, new clip technologies and intraprocedural methods of confirming the patency of parent or perforating vessels (such as fluorescein angiography) may further alleviate postoperative results. Additionally, new ways of training budding neurosurgeons in vascular pathology via interactive virtual simulations and augmented or virtual reality surgeries may rekindle the interest in surgical clipping for future generations.

*DOI: http://dx.doi.org/10.5772/intechopen.88038*

*Preventing Rupture: Clipping of Unruptured Intracranial Aneurysms DOI: http://dx.doi.org/10.5772/intechopen.88038*

Because any unclipped lesion bears a significant risk of rupture, we strongly advocate for the treatment of all aneurysms in patients with MIAs in the same procedure, and if feasible, through the same opening. The techniques and instruments themselves require constant updates in order to minimize postoperative morbidity and mortality while also ensuring ease and comfort in use. In the future, new clip technologies and intraprocedural methods of confirming the patency of parent or perforating vessels (such as fluorescein angiography) may further alleviate postoperative results. Additionally, new ways of training budding neurosurgeons in vascular pathology via interactive virtual simulations and augmented or virtual reality surgeries may rekindle the interest in surgical clipping for future generations.
