ACoA Aneurysm: Inferiorly Projecting

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This video refers to clip ligation of inferiorly projecting ACoA aneurysms. This is a 52 year old female, presented with subarachnoid hemorrhage and was noted to have an ACoA aneurysm on the CTA. The morphology of the aneurysm is better defined on the 3D reconstruction of the CT angiogram. She underwent a right frontotemporal craniotomy due to the dominance of the right A1. This is one of the older videos where I used fixed retractors. The anterior limb of the Sylvian fissure was dissected, the frontal lobe was elevated and the ipsilateral A1 was found. Subfrontal areas being released from the optic apparatus. This is the internal carotid artery. Small portion of the gyrus rectus was removed so that a neck can be exposed. Artery of Heubner was protected here as they don't want the aneurysm. Dissection was diverted more posteriorly around the neck of the aneurysm. Here's the junction of the ipsilateral A1 and the aneurysm neck. I continue dissect over the superior circumference of the neck. Removed, the gyrus rectus was expanded slightly. And just about the superior pole of the neck here, A2 is found. Posterior part of the A2 is apparent at the tip of the arrow. The morphology of the aneurysm is becoming more apparent. I mobilized the brain slightly more posteriorly. Here's the contralateral A1. The inferior circumference of the aneurysm is also better defined now. I assure a safe passageway for the clip blades, both above and below the aneurysm neck. Here's looking all the way across the neck. You can see the dome is somewhat adherent to the optic apparatus, as this aneurysm is inferiorly projecting. Therefore the aneurysm dome cannot be aggressively manipulated. Any traction on the dome can lead to premature rupture. Here's further dissection along the superior neck of the aneurysm until the contralateral A2 is in view. Dissecting above the neck all the way across until the A2 is apparent. Here you can see the A2 coming in to view. The neck is almost ready for deployment and application of the clip. I continue to define the neck as well as possible. A temporary clip was placed under contralateral A1 first. This is done so that in the face of premature rupture, one should not be struggling to gain control over the contralateral A1. For this aneurysm to be generously deflated, I temporarily occluded both A1s. Now the neck is more amenable to manipulation. Since the dome was adherent to the optic apparatus, deflation of the aneurysm was necessary to look all the way around the neck. A straight clip was applied across the neck of the aneurysm. The blades were gradually closed. It's a very broad-based aneurysm. Here's the final result. Small portion of the neck, a very small piece, had to be left behind to keep the ACoA complex patent. Here's the final result. ICG demonstrates exclusion of the aneurysm sack and patency of the surrounding branching vessels. Here's another view of the ICG angiogram. The aneurysm is not filling, and the postoperative imaging excluded any evidence of ischemia and the aneurysm was effectively excluded. Again, a very small piece of the neck was left behind to keep the ACoA patent. Thank you.

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