Let's discuss clip ligation of a small proximal A1 aneurysm. This is an 18 year old male with history of sickle cell disease, with a small questionably ruptured left sided A1 aneurysm. Here's the cerebral arteriogram demonstrating the proximal location of this small aneurysm at the level of A1. Obviously small perforating vessel should be associated with the neck of this aneurysm, and therefore should be found in surgery and saved. Here's a left frontal temporal craniotomy, evidence of subarachnoid hemorrhage is immediately apparent. The anterior aspect of the Sylvian fissure was dissected, and the internal carotid artery was found. The M1 one was also found, and the bifurcation was exposed. Here you can see the carotid artery. Moving toward the bifurcation and A1, you can see there was some fusiform changes. Also at the level of a PCoA, here's A1, here's the ICA bifurcation, here's M1, here is the aneurysm and the small perforating vessel associated with the neck of the aneurysm. I'll go ahead and carefully dissect this perforating vessel. Here's the more distal part of the neck that is been dissected. Aneurysm is relatively small, appears very fragile. I'll go ahead and dissect around the neck as much as possible, so that the clip plates are applied effectively, and not blindly. Here's the angled fenestrated clip, appears to be a good option for this aneurysm. Here's again this perforating vessel being dissected thoroughly from the neck of aneurysm. You can see the interoperative rupture of the aneurysm, despite placement of the temporary clip on the carotid. And further dissecting around the A1, bleeding is not very significant, and under control. You can see the application of the angled fenestrated clip. While preserving the origin of the perforating vessel, I don't want to stenose the A1 significantly either. This perforating vessel appears intact. However, maybe there is a small residual aneurysm, although I'm not sure. That perforating vessel's origin also is spared by the clip plates. Micro-Doppler ultrasonography confirms patency of A1 per fiber inch, so Gelfoam is used to relieve the vasospasm on the small vessels. Intraoperative fluorescent angiography reveals a small residual aneurysm neck. Along the most proximal part of the neck, perforating vessels appear patent. Here's a dome of the aneurysm there, that is now filling. The clip is advanced more proximally. So that it can span across the entire neck. Most of these perforating vessels appear intact. Here's the origin of that tiny perforating vessel that is also spared by their clip plates. Intraoperative ICG angiography confirms exclusion of the aneurysm and patency of these perforating vessels. A micromera was also used to exclude any residual aneurysm neck, and, their ball post fusiform changes around the origin of the PCoA were wrapped in muslin to potentially decrease their chance of further growth of the fusiform changes, and aneurysm formation in this area. Here's the final operative corridor and view of the brain, and the postoperative angiogram demonstrated complete exclusion of aneurysm without an evidence of ischemia on the CT scan. And this patient made an excellent recovery. Thank you.
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