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ACoA Aneurysm: Inferiorly Pointing

November 06, 2014


This is one of my older videos from early on in my career when I used fixed retraction. Let's go ahead and review some of the disadvantages of using fixed retractors for clip ligation of ACoA aneurysms. This is an inferiorly projecting aneurysm. This is a 57 year-old female with a five millimeter ACoA aneurysm. You can see the morphology of the aneurysm. It's relatively simple and again projecting slightly inferiorly. Patient underwent a right frontal temporal craniotomy because of the dominance of the right A1. You see most of the exposure is frontal. Sylvian fissure is located approximately here. The bone is reduced, flushed with the surface of the orbital roof. The dura is opened at curvilinear fashion. I place a suture more posteriorly to avoid epidural bleeding into the operative field. You can see the other sutures placed to accomplish similar tasks and provide an unobstructed subfrontal trajectory. I access the opticocarotid cisterns initially, drain ample minor CSF to achieve early brain relaxation. Elevation of the frontal lobe in this case automatically led to drainage of CSF. Next, the arachnoid bands over the optic nerve are released. The retractor in this case places the arachnoid bands over this sphenoidal segment of the Sylvian fissure under tension. This maneuver directs me to releasing these bands. Next, I continue dissection over the optic nerve. The frontal lobe is released from the optic apparatus. Here is the dissection of this sphenoidal segment of the Sylvian fissure, that was under tension. Olfactory nerve is more apparent. I continue microdissection, releasing the arachnoid bands, tethering the frontal lobe to the carotid artery. Here's the level of the bifurcation, A1 is identified. Here's the lamina terminalis, gentle elevation of the frontal lobe identifies the A1 and leads me to the location of the aneurysm. Here, you can see the contralateral A1, small portion of the gyrus rectus is removed so, the A2 branches are identified. A medial arachnoid band is dissected. I watch for the perforators. Here's the contralateral A2, ipsilateral A2, ipsilateral A1, contralateral A1. A temporary clip may be used on the dominant A1. So, I can further inspect the neck of the aneurysm, mobilize the sack and assure a precise clip application. In this case, it's a very easy clipping because of the projection of the aneurysm, making sure that the clip lights are all the way across the neck of the aneurysm without any compromise of the ACoA. I'm relatively satisfied with this clipping. ICG reveals complete exclusion of the aneurysm with patency of the surrounding branching and perforating vessels. Here again is the dome of the aneurysm, the clip, no evidence of failing of the aneurysm. Perforation of the dome reveals no further filling of the aneurysm. It's a final view of the operative corridor, brain looks relatively healthy. Postoperative angiogram demonstrated complete exclusion of the aneurysm and the CT scan excluded any evidence of ischemia and this patient recovered from her surgery very well. Thank you.

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