December 08, 2015
Let's discuss alternative Clip Ligation Strategies for Anterior Choroidal Artery Aneurysms. This is a 36-year-old female who presented with an acute subarachnoid hemorrhage. CT angiogram demonstrated the location of the Anterior Choroidal Artery Aneurysm, which is relatively broad base. This is separate from the origin of the posterior communicating artery aneurysm. She underwent a right sided frontotemporal craniotomy. The frontal lobe was gently elevated, the entry aspect of the Sylvian fissure was widely dissected. Here is the optic nerve. Sharp dissection was used for distal exposure of the ICA. Here is on tethering of this up frontal area from the optic nerve, continuing the dissection along the carotid artery. The origin of the PCoA is demonstrated. Here's the ICA bifurcation. You can see that the aneurysm is pointing posteriorly. The origin of the Anterior Choroidal Artery is identified early on. Here's the third nerve, each of the tentorium. Let's go ahead and focus our attention on the aneurysm. You can see it's very bulbous. Clip ligation has to be performed parallel to the long axis of the ICA to completely collapse the aneurysm. Let's go ahead and find the origin of the Anterior Choroidal Artery, which is demonstrated here. Here's a better view of the Anterior Choroidal Artery and its origin. I selected an angled fenestrated clip, which is ideal in this situation to collapse and I clip the aneurysm while preserving the Anterior Choroidal Artery origin. The clip is just short of the origin of the Anterior Choroidal Artery. Here, you can see its origin. Let's go ahead and do an ICG angiogram to further confirm the patency of the artery. The aneurysm is excluded. Here is the Anterior Choroidal Artery, which is patent. There is no further filling of the sac. In this case, the postoperative angiogram also confirmed exclusion of aneurysm and patency of the Anterior Choroidal Artery in the postoperative CT skin excluded any evidence of ischemia. This patient recovered from her hemorrhage and surgery without any untoward effects. Thank you.
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