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BACKGROUND: Cowden syndrome is characterized by multiple hamartomas and accompanied by a germline mutation of the phosphatase and tensin homolog gene. Cowden syndrome has been described to be associated with vascular anomalies such as arteriovenous malformation and developmental venous anomalies with high frequency. However, the association of cerebral aneurysms with this syndrome has not been reported yet. CASE DESCRIPTION: A 39-year-old Japanese man presented with a subarachnoid hemorrhage due to a ruptured giant fusiform middle cerebral artery aneurysm. We diagnosed him with Cowden syndrome by clinical presentations as outlined in the National Comprehensive Cancer Network's criteria. As the ruptured fusiform aneurysm involved a middle cerebral artery bifurcation, we prepared for extracranial-intracranial bypass surgery. We successfully performed a surgical clipping using multiple tandem clipping techniques and suction decompression techniques. Bypass surgery was not performed as reconstruction of the M2 trunks was successfully completed. CONCLUSIONS: We present this rare case that potentially indicates an association between cerebral aneurysms and Cowden syndrome. Because vascular anomalies are not included in the diagnostic criteria for Cowden syndrome, intracranial vascular anomalies may be underestimated. We therefore recommended a careful search of vascular diseases, including cerebral aneurysms, in cases of Cowden syndrome.

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BACKGROUND: Treatment of complex unruptured middle cerebral artery (MCA) aneurysms that are untreatable with conventional surgical techniques are rare, and direct aneurysmal clipping usually remains the first-line treatment for large and giant saccular MCA aneurysms. Tandem clipping and multiple clipping techniques represent neck reconstruction in direct clipping surgeries that address these aneurysms. CASE DESCRIPTION: The authors describe a simple variation of neck reconstructive clipping techniques for the large MCA unruptured aneurysm in a patient with an unruptured 20-mm MCA bifurcation aneurysm. The key of this technique is the application of an appropriate initial clip, the "mass reduction clip"; this clip is inserted not into the aneurysmal neck but on the center of the aneurysmal dome so as to compress the dome at first, which yields a change in the aneurysm's shape and reduces the size of the whole aneurysmal mass. This technique facilitates the ensuing neck reconstruction according to the concept of the ideal closure line using few clips. CONCLUSIONS: "Mass reduction" clipping, which changes the shape of the aneurysm and reduces the size of the whole aneurysmal mass, is a useful variation for the treatment of large aneurysms when conventional clipping across the neck is feasible.

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BACKGROUND: Applying more than one clip for a complicated-shaped aneurysm is an established strategy, particularly for middle cerebral arteries (MCA). However, obliterating the cleft of the internal elastic lamina with a single clip is theoretically possible because the line is usually on a single plane. Crankshaft clips were reformed for that purpose decades ago, but are not widely used and have been described in almost no report ever since. METHODS: To reconsider and describe the utility of crankshaft clips for complicated MCA aneurysms and to articulate the advantages and limitations of the clips, we meticulously analyzed a series of more than 150 cases in which the crankshaft clips were used, predominantly for treatment of MCA aneurysms, at Moriyama Memorial Hospital between August 2010 and December 2015. RESULTS: Readjustment of the clip was not necessary in almost all cases, and the first application was the final one. None of the patients had morbidity or mortality related to the surgical technique. To date, we have not experienced any trouble or recurrence. CONCLUSIONS: Crankshaft clips are useful and safe for clipping of complicated MCA aneurysms.

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OBJECTIVE: Although currently only a few middle cerebral artery aneurysms (MCAAs) are inoperable, they still present problems as compared with other aneurysm in the anterior circulaton. MCAAs are less suitable for endovascular surgery, owing to anatomic reasons and frequent association with expanding hematomas, neurosurgeons should focus on the safe treatment of these lesions. Several methods are recently available for the clipping of wide-necked MCAAs. The author emphasizes the techique of multiple clipping in the present study. METHODS: This article contains 5 patients with wide-necked MCAAs who underwent multiple clipping technique with facing and/or tandem fashion, in which the tips of the clip blades are placed in opposite or parallel directions, respectively. RESULTS: Aneurysms were successfully clipped with preservation of the parent vessels. There were four good results and one death directly related to the initial brain injury. CONCLUSION: On the basis of the configurations of domes and their neck, wide-necked MCAAs can be clipped successfully using this multiple clipping technique with facing and tandem fashion.

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