Anterior Choroidal Artery Aneurysm: Nuances of Ligation

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The anterior choroidal artery can often originate from the neck of its aneurysm, and clip ligation remains a very viable strategy for exclusion of these aneurysms. This is a 32 year-old female who presented with thunderclap headache, and was found to harbor xanthrochromia, a lumbar puncture, a cerebral audiogram demonstrated a small interior corridor artery aneurysm. The audio originated from the neck of the aneurysm. She underwent a left frontotemporal craniotomy for clip ligation of her aneurysm, the Sylvian fissure was widely dissected. You can see the exposure, frontal lobe, temporal lobe, Sylvian fissure has been dissected. Arachnoid bands are widely opened. One of the interior bridging veins along the server and fissure had to be sacrificed, and the internal choroidal artery was exposed. Here's the bridging main. Only one had to be sacrificed in this case. Here's the internal choroidal artery securing proximal control. All the arachnoid bands are dissected, and I continue to follow the choroidal artery until the anterior choroidal artery and the aneurysm are found. Here, as you can see, is the neck of the aneurysm, the aneurysm itself, the internal choroidal artery. I'll go ahead and use temporary ICA occlusion to better manipulate the aneurysm and identify the neck away from the origin of the anterior choroidal artery. Here's the temporary clip. Let's go ahead and dissect. Now the neck of the aneurysm, here, you can see the internal choroidal artery wrapping around the neck and distally. The artery is apparent, it is crucial during clip application, not to catch the more distal part of the anterior choroidal artery that wraps around the neck of the aneurysm. Again, the route of this artery has to be carefully visualized. I use a clip, since the clip allows me to visualize the blades much more clearly than a straight clip, assuring that the anterior choroidal artery is out of harm's way. Again, I watch for the more distal part of the artery, as it wraps around the neck of the aneurysm. Let's go ahead and do an ICG, make sure the distal part of the artery is intact as you can see here, and the tip of my arrow, it appears patent on ICG, the aneurysm is occluded. And you can see the distal part of the artery more clearly as I gently retract the ICA. Again, reassuring myself without any doubt that the clip blades are not compromising the anterior choroidal artery at the tip of the clip blades. Here's the final result. The aneurysm's obviously clearly deflated. Dynamic retraction reveals a traumatic operation, and the post-operative angiogram confirmed complete exclusion of the aneurysm with patency of the anterior choroidal artery, and this patient recovered without any ischemia. Thank you.

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