This is an interesting video describing clip ligation of an anterior choroidal artery aneurysm. The artery in this case had at least two branches arising directly from the posterior wall of the ICA. This is a 32 year-old female with an incidental aneurysm along the posterior wall of the internal carotid artery. This is CT angiogram demonstrating the location of the artery with respect to the internal carotid artery and the ICA bifurcation. The PCoA was not involved with the origin of this aneurysm, rather the anterior choroidal artery was affected at its origin from the ICA. Patient underwent a left-sided frontotemporal craniotomy. Sylvian fissure was widely opened. VMC branches were found, and were used as a roadmap toward the ICA bifurcation. Direct stimulation or cortical stimulation can be used for monitoring the motor pathways as you saw there's strip electrode on the surface of the brain. The arachnoid bands along the anterior aspect of the Sylvian fissure are dissected so that the frontal lobe can be mobilized. Here's the M1, continue the dissection along the M1 until the bifurcation is encountered. Here's the area of the bifurcation. I inspect the region for flexible working angles to reach the neck of the aneurysm. Here are some of the perforating vessels of the bifurcation working both posterior and anterior to the bifurcation to localize the location of this aneurysm, which is right to the atypical. See some of the perforating vessels off of the posterior wall of the carotid artery. Go ahead and use dynamic retraction, further inspect the, ICA wall and its posterior aspect. Here is still original the PCoA, again not affected by the aneurysm. And here is the anterior choroidal artery. I'll go ahead and find the neck of the aneurysm as you can see here and inspect the area to make sure the origin of the anterior choroidal artery is protected during deployment of the clip. Here you can see one anterior choroidal artery, and a second one, the second one is smaller. Both of these branches have to be carefully protected during final application of the clip blades. So I'm now investigating the best way to clip this aneurysm parallel to the long axis of the ICA while preserving the origin of the accessory anterior choroidal artery. I'm going to use their space just behind the proximal M1 to pass the clip blades parallel to the long axis of the ICA. Here again is the neck of the aneurysm. Here is the dome of the aneurysm. The aneurysm is relatively sausage-shaped. The perforating vessels are carefully protected. Here you can see the curve clip just coming behind the proximal M1, the clip is placed and the tips are located just short of the origin of the accessory anterior choroidal artery off of the ICA. Temporary clip was used on the ICA, so I connect and manipulate the neck of aneurysm and make sure the clip is applied precisely short of the origin of their accessory artery. You can see the clip blades are sliding somewhat toward the origin of the accessory, anterior choroidal artery. Finally I was able to place the clips just short of the origin of the second anterior choroidal artery or the accessory one. I'm relatively satisfied with where the clip is now. Intraoperative flow seen angiography confirmed complete exclusion of the aneurysm and patency of both anterior choroidal arteries. Again, please note the long axis of the clip parallel to the ICA placement of the clip perpendicular to the ICA can place the origin of the anterior choroidal artery at risk, and also lead to a dog ear and sub optimal exclusion of aneurysm neck. In this case, the post operative angiogram revealed complete exclusion of the aneurysm without any complicating features. And this patient made an excellent recovery, thank you.
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