ACoA Pseudoaneurysm

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This is an extremely rare finding. In other words, formation of a pseudoaneurysm after a clip ligation of a ruptured anterior communicating artery aneurysm. Let's review the intraoperative findings. This is a 66 year-old male who presented with subarachnoid hemorrhage. Angiogram demonstrated an anteriorly projecting anterior communicating artery aneurysm. He underwent a right frontotemporal craniotomy for a clip ligation of the aneurysm. Nine days after the surgery, the CT angiogram demonstrated complete exclusion of the aneurysm. This finding was verified via irregular arteriogram. However, he presented six weeks later with another thunderclap headache and new subarachnoid hemorrhage and was found to have pseudoaneurysm at the base of the previous clip plates. He underwent another right frontotemporal craniotomy. Here's the intraoperative findings. You can see the location of the previous clip. Both A1s were exposed and temporarily clipped. Since I suspected the pseudoaneurysm and a high risk of intraoperative rupture, the aneurysm is now projecting superiorly between the A2s. And here's inspection just behind the A2s to find the pseudoaneurysm. The clip appears to be somewhat still on the neck of the aneurysm. Here we can see part of the pseudoaneurysm. There is very thin wall. There is no robust wall around the pseudoaneurysm here. A fenestrated clip was used in this case to fenestrate the ipsilateral A2 and preserve the anterior communicating artery complex. Here's the final placement of the clip. Again, you can see just some cloth just anterior to the ACoA. There is really not a robust aneurysm present. Artery of Huebner was protected here. Now you can see the location of the pseudoaneurysm. ACoA was protected more posteriorly, and here's the artery of Huebner again within the fenestration. Here's another view of the pseudoaneurysm. I repositioned the clip just to assure myself that the pseudoaneurysm is completely excluded. The clip was advanced a little bit more contralaterally all the way toward the wall of the contralateral A2. Here's another view of the dome of the pseudoaneurysm. There was still some pulsatile activity within the aneurysm. Here's again the location of the older or the initial index aneurysm. Micro Doppler probe investigated the aneurysm. ICG angiography excluded presence of any robust filling of the aneurysm although there was some slight filling of the dome. I felt that the sac most likely will thrombose due to a minimal amount of flow within the aneurysm. All the branching vessels appeared patent. Here again you can see slight filling of the dome in a delayed fashion. I didn't feel I can reposition the clip without placing the adjacent branching vessels at risk. Further inspection reveals some decrease in the pulsatile activity of the pseudoaneurysm indicating gradual thrombosis of the aneurysm. Postoperative 3D angiogram demonstrated complete exclusion of the aneurysm with preservation of the anterior communicating artery and this patient recovered from his surgery uneventfully. Thank you.

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