Single-Stage Bilateral Microsurgical Treatment of Five Complex Unruptured Anterior Circulation Aneurysms Assisted by Rapid Ventricular Pacing: Case Report and Literature Review
5 affiliations
- 1Department of Neurosurgery, Hospital Civil de Guadalajara “Fray Antonio Alcalde”, Guadalajara, Jalisco, Mexico
- 2Department of Neurosurgery, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
- 3Department of Anesthesiology, Hospital Civil De Guadalajara “Fray Antonio Alcalde”, Guadalajara, Jalisco, Mexico
- 4Pediatric Neurosurgery Service, Department of Neurosurgery, Hospital Civil De Guadalajara “Fray Antonio Alcalde”, Guadalajara, Jalisco, Mexico
- 5Faculty of Medicine, Universidad Siglo XXI, Pachuca de Soto, Hidalgo, Mexico
Abstract
Background: Single-stage bilateral microsurgical treatment of multiple anterior circulation aneurysms is uncommon and increases operative complexity. Rapid ventricular pacing (RVP) produces brief, reversible, and titratable systemic hypotension that can facilitate clip reconstruction when prolonged temporary occlusion is undesirable or insufficient.
Case Description: A 54-year-old woman with untreated hypertension and active smoking presented with a pupil-involving left oculomotor nerve palsy and was found to have five unruptured anterior circulation aneurysms: on the left, a paraclinoid internal carotid artery (ICA) aneurysm (Barami type IIIa) and a posterior communicating artery (PCoA) aneurysm; on the right, an ICA C6 blood blister–like lesion, a PCoA aneurysm, and a middle cerebral artery (MCA) M1 pre-bifurcation aneurysm. She underwent sequential left and right mini-pterional craniotomies in a single operative session with bilateral extradural and intradural anterior clinoidectomies. The paraclinoid aneurysm was reconstructed with a 90° fenestrated clip reinforced with a microclip, both PCoA aneurysms were clipped, the blister-like lesion was treated with focal bipolar coagulation under temporary ICA occlusion, and the MCA aneurysm was reconstructed with a straight clip plus a semicurved microclip. RVP was applied in 12 episodes (19 s to 1 min 40 s; 180 bpm) during key reconstruction steps, without arrhythmia requiring intervention or postoperative troponin elevation. Immediate and approximately 2-month postoperative computed tomography angiography (CTA) demonstrated complete aneurysm occlusion. The preoperative left oculomotor nerve palsy persisted, and the modified Rankin Scale (mRS) score was 2 at discharge and at 2-month follow-up.
Conclusion: In this carefully selected patient, single-stage bilateral microsurgery supported by repeated RVP was feasible for the definitive treatment of five complex aneurysms, although persistent cranial neuropathy was observed. The advantages of a single session must be weighed against longer operative time and the morbidity of bilateral craniotomies, and the evidence supporting RVP remains limited to small, noncomparative series.
Related
- A Case of MEN 2A Syndrome With Bilateral Recurrent Pheochromocytoma: A Case Report and Literature Review
- Simultaneous Bilateral Cochlear Implantation in a Child with Warsaw Breakage Syndrome and Normal Cochlear Morphology: A Case Report and Focused Literature Review
- Bilateral multifocal water-clear cell parathyroid adenoma: A case report with literature review
- Contiguous Lumbar Bilateral Pars Defects at L3 and L4 (With Intact L5): Treated With Pedicle Screw Fixation and Interbody Fusion: A Case Report With Literature Review
- Mapping the literature employed to teach law in universities in Anglophonic and Hispanophone countries in the nineteenth century to explore the circulation of legal ideas: Protocol for a scoping review
BibTeX
@article{lopezgonzalez2026singlestage,
title = {{Single-Stage Bilateral Microsurgical Treatment of Five Complex Unruptured Anterior Circulation Aneurysms Assisted by Rapid Ventricular Pacing: Case Report and Literature Review}},
author = {Francisco Javier López-González and Estefany Gilberty Mendoza Verdin and Jose Armando Díaz-Martínez and Regina Rodríguez-Arias and Lorelay Livier Gutiérrez Oliva and Arturo Javier Navarro Gómez and Dominick Manzo Frias},
journal = {International Medical Case Reports Journal},
year = {2026},
month = nov,
doi = {10.2147/imcrj.s644665},
url = {https://doi.org/10.2147/imcrj.s644665},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Single-Stage Bilateral Microsurgical Treatment of Five Complex Unruptured Anterior Circulation Aneurysms Assisted by Rapid Ventricular Pacing: Case Report and Literature Review
AU - Francisco Javier López-González
AU - Estefany Gilberty Mendoza Verdin
AU - Jose Armando Díaz-Martínez
AU - Regina Rodríguez-Arias
AU - Lorelay Livier Gutiérrez Oliva
AU - Arturo Javier Navarro Gómez
AU - Dominick Manzo Frias
PY - 2026
DA - 2026/11/01
JO - International Medical Case Reports Journal
DO - 10.2147/imcrj.s644665
UR - https://doi.org/10.2147/imcrj.s644665
AB - Background: Single-stage bilateral microsurgical treatment of multiple anterior circulation aneurysms is uncommon and increases operative complexity. Rapid ventricular pacing (RVP) produces brief, reversible, and titratable systemic hypotension that can facilitate clip reconstruction when prolonged temporary occlusion is undesirable or insufficient. Case Description: A 54-year-old woman with untreated hypertension and active smoking presented with a pupil-involving left oculomotor nerve palsy and was found to have five unruptured anterior circulation aneurysms: on the left, a paraclinoid internal carotid artery (ICA) aneurysm (Barami type IIIa) and a posterior communicating artery (PCoA) aneurysm; on the right, an ICA C6 blood blister–like lesion, a PCoA aneurysm, and a middle cerebral artery (MCA) M1 pre-bifurcation aneurysm. She underwent sequential left and right mini-pterional craniotomies in a single operative session with bilateral extradural and intradural anterior clinoidectomies. The paraclinoid aneurysm was reconstructed with a 90° fenestrated clip reinforced with a microclip, both PCoA aneurysms were clipped, the blister-like lesion was treated with focal bipolar coagulation under temporary ICA occlusion, and the MCA aneurysm was reconstructed with a straight clip plus a semicurved microclip. RVP was applied in 12 episodes (19 s to 1 min 40 s; 180 bpm) during key reconstruction steps, without arrhythmia requiring intervention or postoperative troponin elevation. Immediate and approximately 2-month postoperative computed tomography angiography (CTA) demonstrated complete aneurysm occlusion. The preoperative left oculomotor nerve palsy persisted, and the modified Rankin Scale (mRS) score was 2 at discharge and at 2-month follow-up. Conclusion: In this carefully selected patient, single-stage bilateral microsurgery supported by repeated RVP was feasible for the definitive treatment of five complex aneurysms, although persistent cranial neuropathy was observed. The advantages of a single session must be weighed against longer operative time and the morbidity of bilateral craniotomies, and the evidence supporting RVP remains limited to small, noncomparative series.
SN - 1179-142X
ER -