Advantages and Pitfalls of the Suction Decompression Method for Direct Clipping of Internal Carotid Artery Aneurysms

Microsurgical treatments for large internal carotid artery (ICA) aneurysms (ANs) are challenging given the large width of both their neck and the adhesion between the dome and the major branches. Here, we report our experience with the clipping of both large-sized and wide neck ICA ANs using the suction decompression (SD) method and discuss its advantages and pitfalls. The clinical data of 13 patients, who underwent SD-assisted direct clipping of ICA ANs, were retrospectively reviewed. Of these, 11 presented ruptured ANs. The ANs were located at the ICA-posterior communicating (IC-PC; 10 cases) and paraclinoid (3 cases) arteries. All ANs were successfully clipped and postoperative computed tomography (CT) angiography revealed the absence of either major branch occlusions or residual ANs. However, postoperative CT also demonstrated infarction in either the anterior thalamoperforating or the anterior choroidal arterial areas in 6 out of 10 patients who harbored IC-PC aneurysms. This resulted in persistent symptoms in 2 subjects, transient symptoms in additional 2 patients, and asymptomatic in the remaining subjects. After the 6-months follow-up period, 10 patients reported good outcome, while the remaining 3 presented severe deficits due to either vasospasms or idiopathic intracerebral hemorrhage. To conclude, the SD method ensures safe clipping of large-sized and wide neck ICA ANs. However, careful observation of the perforators behind the dome and skilled-maneuvers are crucial for avoiding ischemic complications.