A Classic PCoA Aneurysm

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This video describes techniques for a classic posterior communicating artery aneurysm and also technique for clip application. This is a 50 year old female who presented with acute onset headache and evidence of subarachnoid hemorrhage on CT scan. The CT angiogram demonstrated a posterior pointing, posterior communicating artery aneurysm, a classic one at the juncture of the internal carotid artery and the posterior communicating artery. You can see on the coronal images, the location of the aneurysm neck in relation to the entering clinoid process. Furthermore, the neck of the aneurysm is also demonstrated on the actual CTA. And right here when craniotomy was completed, due to the significant swelling of the brain, despite adequate medical measures to relax the brain, I had to use fixer tractors, the internal carotid artery just at the level of the skull base was temporarily occluded. And the neck of the aneurysm was exposed, using microsurgical techniques. You can see sharp dissection is preferred for revealing the neck of the aneurysm, as well as the origin of the posterior communicating artery. Here's removing some of the fibrinous material around in the neck of the aneurysm. This is the more superior, or distal neck of the aneurysm. Here's the location of the posterior communicating artery, turning away from the proximal neck of the aneurysm. The space between the artery and the proximal neck is further developed. You can see that the neck is also pursued further posteriorly and a straight clip is fashioned across the neck of the aneurysm. A longer clip was used, as you can see, I'm turning the clip so that more of the long axis of the blades are parallel to the long axis of the internal carotid artery to avoid any stenosis or torsion on the neck of the aneurysm. This maneuver will also prevent any obvious dog ear remnant. Here is the posterior communicating artery, which, to the patent tip of the blade stopped just short of the posterior communicating artery. Micro doppler ultrasonography confirms adequate patency of the posterior communicating artery as well as the internal carotid artery. This patient tolerated the procedure without any complication. A postoperative angiogram demonstrate complete exclusion of the aneurysm, as you can see on AP and lateral angiography. Furthermore, this patient underwent additional endovascular therapy for her severe spasm that is evident during her vasospasm period. Thank you.

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