This short video describes clip ligation of a small A1 aneurysm. This is a young 26 year old female who presented with acute subarachnoid hemorrhage. CT angiogram demonstrated presence of a very small aneurysm, separate from the ICA bifurcation, based over the proximal A1. This patient underwent a left sided frontotemporal craniotomy. The Sylvian fissure was widely dissected. Here's the optic nerve, the carotid artery. You can see ample amount of blood from the subarachnoid hemorrhage caused by the aneurysm. Further dissection of the fissure more anteriorly, frontal lobe was gently elevated. And dissection continued along the anterior face of the carotid artery torward the bifurcation. Here's continuation of the dissection of the fissures so that the frontal lobe can be further elevated relatively safely. Branches of the MCA are apparent. Here's the ICA bifurcation. The aneurysm should be located just about here. Proximal control is secured over the A1. Let's go ahead now expose the neck of the aneurysm with further gentle elevation of the frontal lobe. Sharp dissection is used. Temporary clip is placed across the ICA since presence of a blister or pseudoaneurysm is possible. Here's this small aneurysm pointing slightly medially. The neck of the aneurysm is circumferentially dissected. There should be one small perforating vessel associated with the neck of the aneurysm. There's one there, there's a separate perforator here. It appears that ample amount of space is available for deployment of the definitive clip. Since the neck is relatively narrow, a straight clip should be able to collapse the entire neck of the aneurysm. Again, here's the origin of the perforating vessels from the neck of the aneurysm. Further dissection along the neck. Here's a straight clip deployed across the entire neck of the aneurysm, perpendicular to A1. Again, since the neck is relatively narrow, perpendicular clipping should be safe. Broader aneurysm neck should be clipped parallel to the axis of the A1. Both perforating vessels are appearing healthy. ICG demonstrates exclusion of the sac and patency of the perforating vessels at the tip of my arrow. And the postoperative angiogram also confirmed exclusion of the aneurysm. The patient recovered from her hemorrhage and surgery without any untoward side effects. Thank you.
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