Complex Fusiform ICA Aneurysms

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This video reviews, microsurgical clip ligation of a complex fusiform proximal internal carotid artery bifurcation aneurysm, as well as a small, ophthalmic artery aneurysm using the retrograde suction decompression technique. This is a patient of mine who presented with subarachnoid hemorrhage, and was diagnosed with at 1.5cm right-sided fusiform proximal ICA aneurysm, as well as a small ophthalmic artery aneurysm, that was more readily appreciated intraoperatively during dissection. You can see the proximal segment of the internal carotid artery is quite dilated and fusiform, very much affected by the aneurysm without any obvious neck, specifically at the mid portion of the internal carotid artery wall. The opthalmic artery aneurysm was not clearly appreciated preoperatively. Although there is a question of a blister aneurysmal change within the wall of the internal carotid artery. This patient underwent a right-sided frontotemporal craniotomy for clip ligation of her ruptured aneurysm. The lesser wing was drilled away and the roof of the optic nerve was also removed. and a clinoidectomy was completed. Both procedures were performed extradurally before the dura is opened. Here's the aneurysmal dilatation of internal carotid artery. Here is the optic nerve. The fusiform ligament was opened. I believe the extradural clinoidectomy is more effective in these cases as a more aggressive bony resection can be completed to expose the proximal internal carotid artery, as well as the optic nerve. The initial dissection revealed this unexpected finding of a small althalmic aneurism just underneath the optic nerve. This finding affected some of the later manipulations to assure that the aneurism is not injured at its neck. So that retrograde suction decompression technique was used. Our intervention colleagues placed a catheter into the internal carotid artery at the level of the neck and a balloon was inflated, and a temporary clip was placed across the internal carotid artery, just distal to the aneurysm neck, and preferably proximal to the anterior carotid artery origin. And a syringe is used within the catheter of the balloon at the level of the neck to achieve retrograde suction and decompression of the aneurysm sack. This maneuver is quite effective in achieving aneurysmal deflation and placement of angled fenestrae clip to reconstruct the lumen of the internal carotid artery. Here is the retrograde suction. You can see dramatic deflation of the aneurism which significantly facilitates dissection of the dome. So enough spaces available for reconstruction of the ICA lumen. A distal clip was also placed. You saw a moment ago, the origin of the anterior caroidal artery, here's this small althalmic aneurism that was managed by a small straight clip. Interoperative fluorescein angiography reveals exclusion of the aneurism, reconstitution of the internal carotid artery lumen and preservation of the anterior choroidal artery origin. Post operative 3D arteriogram demonstrated complete exclusion of this small ophthalmic artery aneurism with preservation of the ophthalmic artery, as well as complete exclusion of the fusiform aneurysm with reconstitution of the internal carotid artery lumen. This patient recovered from her hemorrhage and surgery without any untoward effect and has returned to work since surgery. Thank you.

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