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ACoA Aneurysm: Interhemispheric Approach

August 05, 2015


An alternative method for clip ligation of distal ACoA aneurysms is the interhemispheric approach. Let's go ahead and review this technique for the case of a 48 year old female with an incidental six millimeter distal Anterior Communicating Artery aneurysm. You can see the dominance of the right A1, in this case. The location of the aneurysm is slightly more cranially located away from the level of the anterior cranial fossa. A subfrontal approach would be reasonable, will require removal of a significant portion of gyrus rectus due to cranially located or superiorly located location of this. And through the communicating artery aneurysm, an interhemispheric approach was selected. The craniotomy extended all the way to the level of the frontal sinus so that a direct trajectory toward the neck of aneurysm can be found. Here's the right frontal of craniotomy. Frontal sinus is located just about here. Interhemispheric fissure is dissected. A lumbar drain was used in this case for early decompression. Two sutures were placed within the superior falx. The superior sagittal sinus was gently mobilized toward the contralateral side and the interhemispheric arterial branches were used as a roadmap to find the A2 branches. You can see the interdigitating medial frontal cortices can be quite difficult to dissect of our IP-assisted and continue to dissect the aneurysm. In this approach, the dome of the aneurysm is directly within the operative corridor. I continue dissection around the neck of the aneurysm until the A2 branches were clearly defined. Here you can see the neck of the aneurysm and the A1. A temporary clip was placed to be able to sink on freshly dissect along the dome and the neck of the aneurysm. The neck of the aneurysm was further defined. In here is the A1, the neck of the aneurysm. During dissection, unfortunately, some bleeding was encountered as the arachnoid pans were being dissected. I placed a tentative clip over the area of the bleeding just to be able to stop the bleeding and be able to continue microsurgery. Here's the straight clip just at the point of the tear. The dome was shrunken using bipolar aneurysmal raffy. An angled of clip was used to close at least a portion of the neck. A tentative clip still is in place. You can see the aneurysm neck extends beyond the tip of the initial angled clip. Here's the second clip to close the distal neck. Intra-operative fluorescein as well as ICG angiographies demonstrate complete exclusion of the aneurysm and patency of the branching vessels. Here is further inspection demonstrating the neck of aneurysm that is excluded and the patency of the branching A2 vessels. I was satisfied with the results of clip reconstruction. Here's the final operative corridor. The interhemispheric dissection and the post-operative CT scan then illustrated no evidence of ischemia and this patient recovered from her surgery, uneventfully. Thank you.

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