ACoA Aneurysm: Intraoperative Fluorescence

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This short video describes methods for clip ligation of an anteriorly projecting anterior communicating artery aneurysm. It also reviews some of the advantages of intraoperative fluorescence. This is a 53 year old male who presented with spontaneous subarachnoid hemorrhage and was diagnosed with a relatively small anteriorly projecting ACoA aneurysm responsible for the hemorrhage. He subsequently underwent a left frontotemporal craniotomy due to the dominance of the left A1. Here is the artery of Heubner, left A1. Temporal clip was placed across the dominant A1. So aneurysmal dissection can follow. Here is the contralateral A2. Ipsilateral A2. Additional perforating vessels moving anteriorly. Here's some atherosclerosis at the neck of the aneurysm. The pathway for the clip blades are developed across the neck of the aneurysm all the way across the neck. A finasteride clip was used to collapse the neck while preserving the perforator traveling anteriorly. No residual neck is detected. Both the A2s are patent, relatively easy aneurysm to clip. The blades are flushed with anterior wall of the A2. Interoperative fluorescence, both flouricine and ICG demonstrate complete exclusion of the aneurysm without any complicating features. Some papaverine soaked cotton is used to bathe the small arteries and relieve their vasospasm. Here's the final product. The magnified view of the operative space and postoperative angiogram confirms the desirable result, which is complete exclusion of aneurysm and the CT scan excludes any evidence of ischemia and this patient recovered from his hemorrhage and surgery very well. Thank you.

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