Clipping on sling-wrap method using a polyglycolic acid sheet in a thin-walled or atherosclerotic middle cerebral artery aneurysm: technique note

  • Hidetoshi Matsukawa
  • Kazutaka Uchida
  • Manabu Shirakawa
  • Shinichi YoshimuraEmail author
Technical Note


During surgical treatment of cerebral aneurysm, thin-walled or severe atherosclerotic aneurysms on the middle cerebral artery are sometimes observed. Owing to the vulnerability or stiffness of the aneurysm, simple neck clipping is usually difficult. We aimed to describe a sling-wrap clipping method using a polyglycolic acid (PGA) sheet for thin-walled or atherosclerotic middle cerebral artery aneurysms. The sling-wrap clipping method was performed in six patients with middle cerebral artery aneurysms. After the distal Sylvian approach, the aneurysm and parent artery were slung up like a baby sling by using a transparent PGA sheet. The aneurysm was directly clipped with the PGA sheet by grasping both ends of the sheet and holding them up. Contrary to the existing wrapping methods, our method could directly obstruct the aneurysm under good visibility through the sheet, thereby avoiding slipping in/out of the clip blade. All cases of the sling-wrap clipping method performed in this study were successful. No problems related to this method were encountered. Aneurysm recurrence, allergic reaction to the PGA sheet, and parent artery stenosis were not observed during the follow-up period. The sling-wrap clipping method using a PGA sheet is safe and another surgical option for thin-walled or atherosclerotic middle cerebral artery aneurysms.


Atherosclerosis Sling-wrap clipping method Middle cerebral artery Polyglycolic acid sheet Surgical treatment Thin-walled aneurysm 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This technical note was approved by the institutional ethics committee of Hyogo College of Medicine.

Informed consent

Patient consent was obtained in each case.


  1. 1.
    Abruzzo T, Shengelaia GG, Dawson RC 3rd, Owens DS, Cawley CM, Gravanis MB (1998) Histologic and morphologic comparison of experimental aneurysms with human intracranial aneurysms. AJNR Am J Neuroradiol 19:1309–1314Google Scholar
  2. 2.
    Bederson JB, Zabramski JM, Spetzler RF (1992) Treatment of fusiform intracranial aneurysms by circumferential wrapping with clip reinforcement. Technical note. J Neurosurg 77:478–480. CrossRefGoogle Scholar
  3. 3.
    Brochert A, Reynolds T, Baker R (2003) MRI in a case of muslin-induced granuloma. Neuroradiology 45:82–84. CrossRefGoogle Scholar
  4. 4.
    Choudhari KA (2004) Wrapping and coating of cerebral aneurysms: history, evolution and surgical management after a re-bleed. Br J Neurosurg 18:259–267CrossRefGoogle Scholar
  5. 5.
    Cudlip SA, Kitchen ND, McKhahn GM, Bell BA (1998) Wrapping of solitary ruptured intracranial aneurysms, outcome at five years. Acta Neurochir 140:1167–1170; discussion 1170-1161Google Scholar
  6. 6.
    Deshmukh VR, Kakarla UK, Figueiredo EG, Zabramski JM, Spetzler RF (2006) Long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms. Neurosurgery 58:434–442; discussion 434-442. doi:
  7. 7.
    Doyama H, Tominaga K, Yoshida N, Takemura K, Yamada S (2014) Endoscopic tissue shielding with polyglycolic acid sheets, fibrin glue and clips to prevent delayed perforation after duodenal endoscopic resection. Dig Endosc 26(Suppl 2):41–45. CrossRefGoogle Scholar
  8. 8.
    Felsberg GJ, Tien RD, Haplea S, Osumi AK (1993) Muslin-induced optic arachnoiditis (“gauzoma”): findings on CT and MR. J Comput Assist Tomogr 17:485–487CrossRefGoogle Scholar
  9. 9.
    Frosen J, Piippo A, Paetau A, Kangasniemi M, Niemela M, Hernesniemi J, Jaaskelainen J (2004) Remodeling of saccular cerebral artery aneurysm wall is associated with rupture: histological analysis of 24 unruptured and 42 ruptured cases. Stroke 35:2287–2293. CrossRefGoogle Scholar
  10. 10.
    Fujimura M, Nishijima M, Umezawa K, Hayashi T, Mino Y, Sakuraba T, Midorikawa H (2003) Optochiasmal arachnoiditis following cotton wrapping of anterior communicating artery aneurysm treated by surgical removal of granuloma. J Clin Neurosci 10:254–257CrossRefGoogle Scholar
  11. 11.
    Fujitsu K, Ishiwata Y, Gondo G, Fujii S, Feng DD (1994) Wrap-clipping with a Dacron mesh Silastic sheet. Technical note. J Neurosurg 80:336–337. CrossRefGoogle Scholar
  12. 12.
    Germano A, Priola S, Angileri FF, Conti A, La Torre D, Cardali S, Raffa G, Merlo L, Granata F, Longo M, Tomasello F (2013) Long-term follow-up of ruptured intracranial aneurysms treated by microsurgical wrapping with autologous muscle. Neurosurg Rev 36:123–131; discussion 132. doi:
  13. 13.
    Golling M, Schaudt A, Mehrabi A, Mood ZA, Bechstein WO (2008) Clinical application of soft polyglycolic acid felt for hemostasis and repair of a lacerated liver: report of two cases. Surg Today 38:188–192. CrossRefGoogle Scholar
  14. 14.
    Han MS, Joo SP, Jung SH, Kim TS (2015) Specific and helpful intraoperative indocyanine green videoangiography finding of blood blister-like aneurysm of internal carotid artery. Acta Neurochir 157:1849–1854. CrossRefGoogle Scholar
  15. 15.
    Hassan T, Timofeev EV, Saito T, Shimizu H, Ezura M, Matsumoto Y, Takayama K, Tominaga T, Takahashi A (2005) A proposed parent vessel geometry-based categorization of saccular intracranial aneurysms: computational flow dynamics analysis of the risk factors for lesion rupture. J Neurosurg 103:662–680CrossRefGoogle Scholar
  16. 16.
    Hayakawa M, Katada K, Anno H, Imizu S, Hayashi J, Irie K, Negoro M, Kato Y, Kanno T, Sano H (2005) CT angiography with electrocardiographically gated reconstruction for visualizing pulsation of intracranial aneurysms: identification of aneurysmal protuberance presumably associated with wall thinning. AJNR Am J Neuroradiol 26:1366–1369Google Scholar
  17. 17.
    Ishiwata Y, Inomori S, Fujitsu K, Nishimura S, Hirata K, Gondo G, Yamashita T, Fujino H, Kuwabara T (1990) A new intracranial Silastic encircling clip for hemostasis. Technical note. J Neurosurg 73:638–639. CrossRefGoogle Scholar
  18. 18.
    Kadasi LM, Dent WC, Malek AM (2013) Cerebral aneurysm wall thickness analysis using intraoperative microscopy: effect of size and gender on thin translucent regions. J Neurointerventional Surg 5:201–206. CrossRefGoogle Scholar
  19. 19.
    Kawase T, Gotoh K, Toya S (1994) A wrapping clip combined with silastic sheet for emergent hemostasis: technical note. Neurosurgery 35:769–770; discussion 770-761Google Scholar
  20. 20.
    Kirollos RW, Tyagi AK, Marks PV, van Hille PT (1997) Muslin induced granuloma following wrapping of intracranial aneurysms: the role of infection as an additional precipitating factor. Report of two cases and review of the literature. Acta Neurochir 139:411–415CrossRefGoogle Scholar
  21. 21.
    Kondo S, Hashimoto N, Kikuchi H, Hazama F, Nagata I, Kataoka H (1998) Apoptosis of medial smooth muscle cells in the development of saccular cerebral aneurysms in rats. Stroke 29:181–188 discussion 189CrossRefGoogle Scholar
  22. 22.
    Kurita H, Shiokawa Y, Segawa H, Kirino T (1995) Delayed parent artery narrowing occurring months after aneurysm surgery: a complication after aneurysm surgery--technical case report. Neurosurgery 36:1225–1229CrossRefGoogle Scholar
  23. 23.
    Kuroki T, Aoki K, Aoki Y, Nemoto A, Yamazaki T, Katsume M, Takasu N (2003) Cranial nerve pareses following wrapping of a ruptured dissecting vertebral artery aneurysm: a possible complication of cyanoacrylate glue--case report. Neurol Med Chir (Tokyo) 43:35–37CrossRefGoogle Scholar
  24. 24.
    Lee BH, Kim BM, Park MS, Park SI, Chung EC, Suh SH, Choi CS, Won YS, Yu IK (2009) Reconstructive endovascular treatment of ruptured blood blister-like aneurysms of the internal carotid artery. J Neurosurg 110:431–436. CrossRefGoogle Scholar
  25. 25.
    Meckel S, Singh TP, Undren P, Ramgren B, Nilsson OG, Phatouros C, McAuliffe W, Cronqvist M (2011) Endovascular treatment using predominantly stent-assisted coil embolization and antiplatelet and anticoagulation management of ruptured blood blister-like aneurysms. AJNR Am J Neuroradiol 32:764–771. CrossRefGoogle Scholar
  26. 26.
    Meng H, Wang Z, Hoi Y, Gao L, Metaxa E, Swartz DD, Kolega J (2007) Complex hemodynamics at the apex of an arterial bifurcation induces vascular remodeling resembling cerebral aneurysm initiation. Stroke 38:1924–1931. CrossRefGoogle Scholar
  27. 27.
    Mishiro T, Shibagaki K, Matsuda K, Fukuyama C, Okada M, Mikami H, Izumi D, Yamashita N, Okimoto E, Fukuda N, Aimi M, Fukuba N, Oshima N, Takanashi T, Matsubara T, Ishimura N, Ishihara S, Kinoshita Y (2016) Successful endoscopic management of non-healing perforated duodenal ulcer with polyglycolic acid sheet and fibrin glue. ACG Case Rep J 3:e197. CrossRefGoogle Scholar
  28. 28.
    Nakamura T, Shimizu Y, Watanabe S, Hitomi S, Kitano M, Tamada J, Matsunobe S (1990) New bioabsorbable pledgets and non-woven fabrics made from polyglycolide (PGA) for pulmonary surgery: clinical experience. Thorac Cardiovasc Surg 38:81–85. CrossRefGoogle Scholar
  29. 29.
    Nakano S, Iseda T, Yoneyama T, Ikeda T, Goya T, Wakisaka S (2000) A combination of wrapping and clipping using a collagen-impregnated dacron fabric (hemashield). Surg Neurol 53:330–333CrossRefGoogle Scholar
  30. 30.
    Ogawa A, Suzuki M, Ogasawara K (2000) Aneurysms at nonbranching sites in the surpaclinoid portion of the internal carotid artery: internal carotid artery trunk aneurysms. Neurosurgery 47:578–583 Cranial nerve pareses following wrapping of a ruptured dissecting vertebral artery aneurysm: a possible complication of cyanoacrylate glue--case reportGoogle Scholar
  31. 31.
    Onoue H, Abe T, Tashibu K, Suzuki T (1992) Two undesirable results of wrapping of an intracranial aneurysm. Neurosurg Rev 15:307–309Google Scholar
  32. 32.
    Prabhu SS, Keogh AJ, Parekh HC, Perera S (1994) Optochiasmal arachnoiditis induced by muslin wrapping of intracranial aneurysms. A report of two cases and a review of the literature. Br J Neurosurg 8:471–476CrossRefGoogle Scholar
  33. 33.
    Repka MX, Miller NR, Penix JO, Trant JH 3rd (1984) Optic neuropathy from the use of intracranial muslin. J Clin Neuroophthalmol 4:147–150Google Scholar
  34. 34.
    Sadasivan B, Ma S, Dujovny M, Ho LK, Ausman JI (1990) Use of experimental aneurysms to evaluate wrapping materials. Surg Neurol 34:3–7CrossRefGoogle Scholar
  35. 35.
    Shimada Y, Hongo M, Miyakoshi N, Sugawara T, Kasukawa Y, Ando S, Ishikawa Y, Itoi E (2006) Dural substitute with polyglycolic acid mesh and fibrin glue for dural repair: technical note and preliminary results. J Orthop Sci 11:454–458. CrossRefGoogle Scholar
  36. 36.
    Ueda K, Tanaka T, Hayashi M, Li TS, Tanaka N, Hamano K (2011) Mesh-based pneumostasis contributes to preserving gas exchange capacity and promoting rehabilitation after lung resection. J Surg Res 167:e71–e75. CrossRefGoogle Scholar
  37. 37.
    Uemura K, Murakami Y, Hayashidani Y, Sudo T, Hashimoto Y, Ohge H, Sueda T (2009) Combination of polyglicolic acid felt and fibrin glue for prevention of pancreatic fistula following pancreaticoduodenectomy. Hepatogastroenterology 56:1538–1541Google Scholar
  38. 38.
    van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J (1988) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:604–607CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryHyogo College of MedicineNishinomiyaJapan

Personalised recommendations