Distal PICA Aneurysm
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Distal PICA aneurysms are relatively rare. This is a case of a 43 year old female who presented with spontaneous subarachnoid hemorrhage and a 3D cerebral arteriogram demonstrated this distal relatively fusiform PICA aneurysm. She subsequently underwent a midline suboccipital craniotomy in the prone position. The tonsils were micro-surgically separated. The distal segment of the PICA was isolated and followed between the tonsils into the fourth ventricle. I suspected the aneurysm would be somewhat around the posterior roof of the fourth ventricle. Again following the route of the artery. Here's the choroid plexus, soar just into the fourth ventricle. All of the arachnoid adhesions were sharply dissected. You can see now the enter aneurysm essentially incorporating the distal PICA into its neck. Therefore, reconstruction of the neck using fenestrated angled clips would be appropriate. Here is the portion of the PICA distal to the aneurysm, proximal to the aneurysm. Temporary clipping would be advantageous to our low deflation of the aneurysm and reconstruction of the lumen of the PICA. A long clip can be problematic for reconstructing the lumen without a dog ear as you can see here. In these circumstances is best to use two smaller fenestrated clips to be able to close the entire neck of the aneurysm, especially around a curvature of the vessel. Here's the final result. Let's go ahead and do an intraoperative ICG angiogram to better study the flow within the vessels. You can see the vessel is patent. The aneurysm is completely excluded. In the dome of the aneurysm is apparent at the tip of my surgical instrument. Dome is apparent here. Postoperative CT scan excluded any evidence of ischemia, angiogram confirmed complete exclusion of the aneurysm without any complicating features. Thank you.
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