Surgical audit of ruptured intracranial anterior circulation aneurysm clipping in Neurosurgery Unit II, Punjab Institute of Neurosciences, Lahore.


  • Mubashir Malik Department of Neurosurgery, PINS, Lahore.
  • Shehzad Safdar
  • Fauzia Sajjad
  • Abdul Ghafoor
  • Usama Mansoor
  • Amir Aziz



Anterior circulation aneurysm, Ruptured aneurysms, Surgical clipping


Objective:To review and document the rates of morbidity and mortality after surgical clipping for ruptured intracranial anterior circulation aneurysms in the department of Neurosurgery Unit II at Punjab Institute of Neurosciences, Lahore.

Methods:Retrospective observational study was done. Doctors’ and nurses ‘notes, and radiology were reviewed to analyze the outcome of patients after microsurgical clipping.

Results:180 patients were included according to non-probability, consecutive sampling. Mean age = 44.32±13.75 years, male to female ratio of 2.05:1. Fisher grade was: Grade I – 89.4%, Grade II-6.7% and Grade III- 3.9%. WFNS grade was: Grade I- 83.9%, Grade II – 11.1%, Grade III – 1.7% and Grade IV – 3.3%. Hunt and Hess grade was: Grade I- 47.4%, Grade II-25%and Grade III- 0.6% (p=<0.001)(Confidence Interval-CI=95%). Anterior Communicating Artery aneurysms were 47.22 % (p=0.50), Middle Cerebral Artery aneurysms 28.3% (p<0.001), Internal Cerebral Artery aneurysms 8.9%(p<0.001), Distal Anterior Cerebral Artery aneurysm 8.3% (p<0.001) and Posterior Communication Artery aneurysms 7.2%(p<0.001). , A temporary clip was applied during surgery in 13.3% only.The results showed the incidence of these outcomes as: Acute New onset Neurological Deterioration/Deficit was documented in 6.1%), Rebleeding 3.3%, Vasospasm 5.0%, Revision surgery 6.1% and Mortality in 8.3% (p<0.001).

Conclusion:T the outcome of patients who underwent surgical clipping of ruptured anterior circulation aneurysms in the department of Neurosurgery Unit II, Punjab Institute of Neurosciences, Lahore, is comparable to the results of the studies and trials in the published literature.


vanDijk JM, Groen RJ, TerLaan M, Jeltema JR, Mooij JJ, Metzemaekers JD. Surgical clipping as the preferred treatment for aneurysms of the middle cerebral artery. ActaNeurochir (Wien). 2011;153(11):2111-2117. doi:10.1007/s00701-011-1139-6

Zhu W, Ling X, Petersen JD, Liu J, Xiao A, Huang J. Clipping versus coiling for aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of prospective studies. Neurosurg Rev. 2022;45(2):1291-1302. doi:10.1007/s10143-021-01704-0

Sharma, Rajan Kumar & Yamada, Yasuhiro &Kawase, Tsukasa & Kato, Yoko. (2019). To clip or coil? Proposal of individual decision making. Interdisciplinary Neurosurgery. 17. 10.1016/j.inat.2019.04.001.

Ahmed SI, Javed G, Bareeqa SB, et al. Endovascular Coiling Versus Neurosurgical Clipping for Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis. Cureus. 2019;11(3):e4320. DOI 10.7759/cureus.4320.

Tewari M, Aggarwal A, Mathuriya S, Gupta V. The outcome after aneurysmal sub arachnoid hemorrhage: a study of various factors. Ann Neurosci. 2015;22(2):78-80. doi:10.5214/ans.0972.7531.220205

Fang Y, Xu S, Lu J, et al. Validation and Comparison of Aneurysmal Subarachnoid Hemorrhage Grading Scales in Angiogram-Negative Subarachnoid Hemorrhage Patients. Biomed Res Int. 2020;2020:9707238. Published 2020 Feb 28. doi:10.1155/2020/9707238

Huang, G., Sun, Y., Li, J. et al. Therapeutic Effects of Microsurgical Clipping at Different Time Points on Intracranial Aneurysm and Prognostic Factors. Artery Res 27, 135–142 (2021).

Green, A. & van Rij, Andre & Watters, David &Dewan, P. &Poxon, V. & Montgomery, P.. (2002). Surgical Audit and Peer Review: A Guide.

Shea AM, Reed SD, Curtis LH, Alexander MJ, Villani JJ, Schulman KA. Characteristics of nontraumatic subarachnoid hemorrhage in the United States in 2003. Neurosurgery. 2007;61(6):1131-1138. doi:10.1227/

Rinkel GJ, Djibuti M, Algra A, van Gijn J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review. Stroke. 1998;29(1):251-256. doi:10.1161/01.str.29.1.251

Jordan LC, Johnston SC, Wu YW, Sidney S, Fullerton HJ. The importance of cerebral aneurysms in childhood hemorrhagic stroke: a population-based study. Stroke. 2009;40(2):400-405. doi:10.1161/STROKEAHA.108.518761

Gauvrit JY, Leclerc X, Ferré JC, et al. Imagerie de l'hémorragie sous-arachnoïdienne [Imaging of subarachnoid hemorrhage]. J Neuroradiol. 2009;36(2):65-73. doi:10.1016/j.neurad.2008.06.005

Mooij JJ. Editorial: grading and decision-making in (aneurysmal) subarachnoid haemorrhage. IntervNeuroradiol. 2001;7(4):283-289. doi:10.1177/159101990100700402

Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care. 2005;2(2):110-118. doi:10.1385/NCC:2:2:110

Keedy A. An overview of intracranial aneurysms. Mcgill J Med. 2006;9(2):141-146.

Diaz FG, Fessler RD, Velardo B, Kennedy C, Wilner H. Anterior circulation aneurysms: surgical perspectives. J ClinNeurosci. 1994;1(4):222-230. doi:10.1016/0967-5868(94)90062-0

Kumar S, Sahana D, Menon G. Optimal Use of Temporary Clip Application during Aneurysm Surgery - In Search of the Holy Grail. Asian J Neurosurg. 2021;16(2):237-242. Published 2021 May 28. doi:10.4103/ajns.AJNS_465_20

Kang Xk, GuoSf, Lei Y, Wei W, Liu Hx, Huang Ll, Jiang Ql. Endovascular coiling versus surgical clipping for the treatment of unruptured cerebral aneurysms: Direct comparison of procedure-related complications. Medicine 2020;99:13(e19654).

Mahaney KB, Todd MM, Bayman EO, Torner JC; IHAST Investigators. Acute postoperative neurological deterioration associated with surgery for ruptured intracranial aneurysm: incidence, predictors, and outcomes [published correction appears in J Neurosurg. 2020 Feb 07;132(6):2009]. J Neurosurg. 2012;116(6):1267-1278. doi:10.3171/2012.1.JNS111277

Johnston SC, Dowd CF, Higashida RT, et al. Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the Cerebral Aneurysm ReruptureAfter Treatment (CARAT) study. Stroke. 2008;39(1):120-125. doi:10.1161/STROKEAHA.107.495747

Obermueller, K., Hostettler, I., Wagner, A. et al. Frequency and risk factors for postoperative aneurysm residual after microsurgical clipping. ActaNeurochir 163, 131–138 (2021).

Muirhead WR, Grover PJ, Toma AK, Stoyanov D, Marcus HJ, Murphy M. Adverse intraoperative events during surgical repair of ruptured cerebral aneurysms: a systematic review. Neurosurg Rev. 2021;44(3):1273-1285. doi:10.1007/s10143-020-01312-4

Proust F, Hannequin D, Langlois O, Freger P, Creissard P. Causes of morbidity and mortality after ruptured aneurysm surgery in a series of 230 patients. The importance of control angiography. Stroke. 1995;26(9):1553-1557. doi:10.1161/01.str.26.9.1553

Dasenbrock HH, Smith TR, Rudy RF, Gormley WB, Aziz-Sultan MA, Du R. Reoperation and readmission after clipping of an unruptured intracranial aneurysm: a National Surgical Quality Improvement Program analysis. J Neurosurg. 2018;128(3):756-767. doi:10.3171/2016.10.JNS161810

Alshekhlee A, Mehta S, Edgell RC, et al. Hospital mortality and complications of electively clipped or coiled unruptured intracranial aneurysm. Stroke. 2010 Jul;41(7):1471-1476. DOI: 10.1161/strokeaha.110.580647. PMID: 20522817.

Anderson, I. A., Kailaya-Vasan, A., Nelson, R. J., and Tolias, C. M. (2019). Clipping aneurysms improves outcomes for patients undergoing coiling. Journal of Neurosurgery JNS 130, 5, 1491-1497, available from: <> [Accessed 09 August 2022

Stauning, A.T., Eriksson, F., Benndorf, G. et al. Mortality among patients treated for aneurysmal subarachnoid hemorrhage in Eastern Denmark 2017–2019. ActaNeurochir (2022).






Original Articles