ACoA Aneurysm: Methods to Avoid Retractors

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Let's review the use of fluorescence for clip ligation of an anterior communicating artery aneurysm. This is a 62-year-old female who presented with a ruptured 10 millimeter ACoA aneurysm. Due to her renal function, she underwent an MRA, demonstrating the morphology of the aneurysm, which is essentially anteriorly pointing and the left A1 is the dominant one. She subsequently underwent a left frontotemporal craniotomy. The roof of the orbit was drilled flat. Sylvian fissure was dissected along its anterior aspect. The fibrinous material around the aneurysm was also dissected. Here is that the dissection of the anterior aspect of the Sylvian fissure. Lamina terminalis was opened. Temporary clip was placed on A1 ipsilaterally. The A2 branch contralaterally was found. Here's the ipsilateral one. I looked underneath the aneurysm neck and a straight clip was placed across the neck using dynamic retraction to mobilize the aneurysm and secure the tip of the aneurysm just anterior to the A2's. Intraoperative fluorescein angiography, as well as ICG angiography demonstrated complete exclusion of the aneurysm and patency of the adjacent branching vessels. You can see that in deep operative corridors, such as operative corridors for A1 aneurysms, the fluorescence functions better than ICG in terms of resolution of the imaging. And here's is a view of our post operative corridor, and this patient recovered from her surgery uneventfully. Thank you.

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