# Microsurgical Clipping of Wide-Neck Anterior Circulation Aneurysms: A Case Series From a Low- and Middle-Income Country

## TL;DR

This study examines the effectiveness of microsurgical clipping for treating wide-neck aneurysms in a low-resource setting, showing it can be a viable alternative to costly endovascular methods.

## Contribution

The study provides real-world evidence supporting microsurgical clipping for wide-neck aneurysms in resource-limited countries.

## Key findings

- Microsurgical clipping achieved favorable outcomes in six out of eight patients.
- One aneurysm required endovascular follow-up due to a neck remnant.
- Two patients experienced mortality, highlighting risks associated with the procedure.

## Abstract

Background

Aneurysms of the anterior circulation are the most prevalent of intracranial aneurysms, most of which are saccular. Wide-neck aneurysms (WNAs) are a specific subtype of intracranial aneurysms that are difficult to treat. Adequate endovascular management of such aneurysms requires assistive devices that are either too costly or sometimes unavailable in our setting as a resource-limited country, strongly supporting the resurgence of microsurgical clipping in the management of such understudied aneurysms. In this study, we aim to assess the short- and intermediate-term radiological and functional outcomes of microsurgical clipping in a resource-limited country.

Methodology

This is a case series study conducted from January 2022 to January 2024. All patients with wide neck anterior circulation aneurysms who were managed by microsurgical clipping were included in this study. Clinical, radiological, and functional outcomes were reported at 3 months and 6 months as short- and intermediate-term outcomes, respectively.

Results

Nine WNAs of the anterior circulation in eight patients were included. Five patients were males and three were females. AcomA was the most common location of three aneurysms. All our patients presented with ruptured aneurysms except one mirror-image M2 aneurysm. All aneurysms were completely clipped except one PcomA aneurysm that had a neck remnant that was diagnosed and managed endovascularly with a flow diverter. Six patients had favorable outcomes at discharge (modified Rankin score of 0-2). We had one case of intraoperative rupture, a single case of hydrocephalus that was treated with a ventriculoperitoneal shunt, and two cases of mortality, one of them due to delayed ischemic neurological deficit. All ruptured aneurysms were clipped using two clips. The unruptured aneurysm in the patient with two mirror-image M2 aneurysms was managed with a single clip 3 months after the ruptured one.

Conclusion

Microsurgical clipping continues to be a viable option in the management of WNAs both radiologically and functionally, especially in our setting as a resource-limited country where endovascular management could be costly and sometimes not available.