Clipping is a tried-and-true method of treating an aneurysm, a bulge in a weak area of an artery.
Artery walls are under constant pressure from the high-pressure blood flow inside them. The constant pressure can cause a weak area of the wall to balloon out, forming an aneurysm. The main risk of an aneurysm is that the ballooning area may eventually burst, spilling blood into the brain. This causes a hemorrhagic stroke, a medical emergency that may cause disability or death.
Clipping is a way to treat an aneurysm by placing a small metal clip across the neck of the aneurysm- the base of the bulge. The aneurysm is thereby sealed off from the blood flow; it cannot burst or spill blood into the brain.
Clipping may be performed on a ruptured or unruptured aneurysm.
Recall that a ruptured aneurysm causes hemorrhagic stroke- a serious medical emergency. Clipping of a ruptured aneurysm, therefore, is performed on an emergency basis. First, a patient arrives at the emergency department and the ruptured aneurysm is identified. Then the patient may be brought directly to the operating room if there is a chance that clipping the aneurysm will help the patient.
Unruptured aneurysms may be serious, but they are usually not immediate medical emergencies. There is generally time to develop a treatment plan with a neurosurgeon, and to get a second opinion if desired. Unruptured aneurysms are sometimes found incidentally or as part of a screening program for patients with a family history of aneurysms.
Not all unruptured aneurysms will be surgically treated. An experienced neurosurgeon can help a patient weigh his or her individual risk of aneurysm rupture against the small but real risks of brain surgery. If the risk of rupture is quite small, the better course might be to monitor the aneurysm for any changes. If the risk of rupture is moderate or great, surgical treatment may be indicated.
Clipping is performed under general anesthesia.
First the patient’s head is stabilized so that it cannot move during surgery.
Then the surgeon cleans the scalp. No hair shaving is required. An incision is made completely behind the hairline (like a facelift incision). Then the skin is reflected aside, but the muscle is left undisturbed. A small bone opening is then made above the eyebrow to create a “window” in the skull through which the brain can be accessed.
Next the surgeon opens the dura, the protective covering around the brain. Then the surgeon locates the aneurysm, which is in the fluid space underneath the brain. The surgeon must achieve vascular control of the aneurysm. Once vascular control is achieved, the surgeon gently detaches the aneurysm from any structures around it, so that the entire neck of the aneurysm can be seen.
Making sure not to clip any other vessels, the surgeon places the clip over the entire neck of the aneurysm. More than one clip may be used. Then the surgeon checks that the aneurysm is fully sealed off. The clip or clips will stay in place permanently.
Finally, the surgeon closes the surgical openings. The dura is closed with stitches. To close the opening in the skull, the surgeon uses thin metal plates and screws to reattach the small piece of bone that was removed at the beginning of surgery. (Like any other fractured bone, the skull will heal itself over the course of weeks and months, growing back into one solid bone again. The plates and screws can stay in after the skull is healed, however; they do not need to be removed.) The surgeon sews up the skin incision.
Make sure you understand the risks and goals of your procedure. It may help to write down questions as you think of them and bring your questions to your appointments.
Give your surgeon a complete list of your medications and their schedule. Ask if your medication schedule should be changed in any way for surgery.
How long will I stay in the hospital?
Hospital stay varies widely. The main factor is whether or not the aneurysm ruptured before the procedure.
Patients who had an unruptured aneurysm typically stay in the hospital for two days.
Patients who had a ruptured aneurysm will stay in the hospital for two-three weeks. During that time, patients are monitored for serious side effects possible after a bleed in the brain. These include vasospasm, hydrocephalus, problems with the heart and lungs or other conditions.
Will I need to take any special medications?
Postoperative pain control will be achieved with pain medication. Patients who had a ruptured aneurysm may receive other medication related to the hemorrhage or any side effects.
Will I need rehabilitation or physical therapy?
Some patients will need rehabilitation or physical therapy, particularly if there was a ruptured aneurysm that caused damage to brain tissue. It may take some time- weeks, months or even years- to understand the effects of the damage and to regain maximum function.
Will I have any long-term limitations due to aneurysm clipping?
Most aneurysm clips are “MR compatible,” meaning they can safely enter an MRI machine. (MRI machines use powerful magnets, and it is vital that any metal that could be affected by magnets not enter an MRI machine.) However, you should double-check with your surgeon. Make sure you know whether your clips are MR compatible.
The plates and screws that close the craniotomy are MR-compatible. They can safely enter an MRI machine.
Department chair Dr. Robert Solomon and Dr. E. Sander Connolly are experts in the surgical clipping of aneurysms. They are also available for second opinions.
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