This is one of the cases early on in my career. This is a 42 year-old female who presented with subarachnoid hemorrhage and a large right frontal intracerebral hemorrhage associated with this anterior pointing ACom aneurysm. The dominant A1 is contralateral to the site of the hemorrhage. However, to avoid any injury to the intact frontal lobe, I approached the aneurysm from the side of the hemorrhage and the non-dominant A1. In other words, proximal control can be quite challenging. In addition, the brain would be quite swollen in the presence of the large hemorrhage. Right frontal tumor craniotomy was completed. A portion of the hematoma was removed from the subfrontal area to decompress the brain. However, the brain remained quite tense. I did not remove all the hemorrhage to avoid the risk of premature rupture. Here is the right optic nerve, chiasm. You can see the dome of the aneurysm is quite adherent to the chiasm. I attempted to gently mobilize the dome to be able to obtain proximal control of the contralateral A1. Due to the far location of the contralateral A1, access to this structure was not possible without gentle mobilization of the aneurysm. However, a premature rupture would be quite daunting to handle because there's no proximal control available yet. Here's some small amount of bleeding from the dome of the aneurysm that became quite more vigorous. Without proximal control, the options are quite limited. And as bleeding became more vigorous, I attempted to control the bleeding from the dome of the aneurysm via bipolar coagulation. Here's an intense amount of bleeding. I had no proximal control and I proceeded with coagulation of the dome as far away as possible from the optic nerve. In order to mobilize the dome away from the chiasm, I cut a part of the dome in order to protect the optic apparatus. And the optic apparatus is located here. The dome is being coagulated. And this is a last resort commando operation. Now the coagulated part of the dome is being disconnected from the chiasm. This maneuver allowed me to mobilize the dome away from the chiasm and obtain proximal control over the contralateral A1. Temporary clip was placed on the contralateral A1. You can see the ipsilateral optic nerve, contralateral optic nerve and the chiasm and a part of the coagulated dome of the aneurysm attached to the super part of the chiasm. After temporary control is secured, I placed a straight fenestrator clip across the neck of the aneurysm while sparing the ipsilateral A2's origin. You can see the dome of the aneurysm. Post operative CT and CT angiogram all demonstrated the desirable result. In other words, the hematoma was completely evacuated and the aneurysm was completely excluded and this patient remarkably did well after the surgery. Thank you.
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