Calcified PCoA Aneurysm: Intraoperative Rupture

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This video describes the pitfalls for application of definitive clips across the aneurysms in general and most spectifically PCoA Aneurysm. This is 68 year-old female who presented with a partially thrombosed PCoA aneurysms and more specifically PCoA aneurysms. The morphology of the aneurysm and its partial thrombosis is demonstrated. You can see most of the aneurysm is filled with thrombus. There is a small lumen in the middle of aneurysm that is still live and patent. Here you can see the lumen within the aneurysm due to presence of third nerve palsy. She under went repair of this aneurysm, this is one of my older videos. When I used fixers tractors more liberally left frontotemporal craniotomy is completed. Sphenoid wing is partially through all the way frontal lupus gently elevated. The anterior or sphenoidal segment of the phishery is dissected. You can see the arachnoid bands of the phish robe are placed under tension. The MC vessels are used as roadmaps to continue dissection of the phisher. The M one is found in this case and further dissection exposes the proximal ICA. Here's the use of sharpest section, just following the contours of the sphenoid wing. And these are basic techniques for exposure of PCoA aneurysms. Here's the optic nerve via arachnoid bands over the optical carotid cisterns, the exposure wall, identify the origin of the aneurysm and its neck. knives are quite effective for exposing the optic nerve and releasing the frontal lobe so that a longer length of the ICA can be rearly exposed. Here again is the proximal ICA dissection continuous along the anterior wall of the IC. So that neck of the aneurysm is exposed and proximal distal control are secured. Further dissection are their acne bands over the Ipsilateral optic nerve is demonstrated. The aneurysm is most likely located here. Therefore, the frontal lobe has to be further mobilized in the temporal lobe gently. Mobilized posteriorlly. The arachnoid bands over the neck of the aneurysm are dissected. Here now you can appreciate that this little neck of the aneurysm and a proximal neck, the origin of the PCoA located here. If fixer tractors are used, you can see their configuration ears de PCoA just medial to the internal quarter artery curving posteriorly through the memory, Some of the perforating vessels are also evident. And here's the location of the aneurysm, the liquid membrane, the optic nerve, the carotid artery here's the origin or the PCoA along the proximal, neck of aneurysm. The clip blades should be placed as parallel as possible to the long axis of the internal Crowder artery, especially for an aneurysm that is broad-based basin partially thrombosed. Here's their morphology of the aneurysm under ICG angiogram before its clipping. If the clip lights are placed perpendicular to the internal carotid artery as demonstrated here, and they don't spend the entire neck of the aneurysm, the hemodynamic changes within the SAC upon partial neck clipping can lead to intra-operative rupture. Here you can see the neck was not completely dissected. The clip lays are probably being inserted slightly blindly. Here you can see the intraoperative hemorrhage, Despite the presence of a temporary clip on the ICA. Therefore this clip was removed. Further dissection is necessary to assure that the entire Nick of aneurysm is exposed. Here's a longer clip after the neck is more readily available with a better view across the entire neck of aneurysm all the way through. This time, the neck is more adequately secured, no further bleeding is apparent. Temporary clip is removed. PCOM is patted. Here's a view of the PCoA just medial to the internal carotid artery. The aneurysm is excluded. I'm satisfied with the configuration of the clip and patency of a branching vessels. The aneurysm is penetrated. So it's decompressed so that the chance of resolution of the third nerve palsy is improved. And here's the postoperative imaging. No evidence of schema is apparent and aneurysm is completely excluded in this patient, palsy recovered within weeks after her surgery. Thank you.

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