This video demonstrates techniques for clip ligation of fusiform distal PICA aneurysms. This is a 66 year-old female who presented with subarachnoid hemorrhage from this small PICA aneurysm. You can see the location of the aneurysm, which is relatively proximal along the PICA segment. The aneurysm is relatively fusiform, without any well-defined neck. Patient underwent a left lateral suboccipital craniotomy. Cerebral was gently elevated, the lower cranial nerves were identified, all the rack node bands were dissected. You can see that the aneurysm is hidden behind the lower cranial nerves. I worked between the cranial nerves to expose the neck of the aneurysm. The aneurysm appears slightly atherosclerotic. There's a very small amount of space to work through. Small perforator is associated with it; dome or the mid-body of the aneurysm sac. This vessel is mobilized. You can see the fuse, the form feature of this aneurysm. Temporary clip was applied and I used an angled fenestrated clip to exclude the aneurysm, while preserving the perforating vessel, as was the lumen of the PICA. Micro Doppler probe confirmed patency of the PICA. In addition, intraoperative fluorescein angiography confirmed similar findings. You can see the use of the angled fenestrated technique in this case. Fluorescein angiography is quite effective in deep operative corridors. Perforator appears intact next to the clip blades. Lower cranial nerves look healthy. And postoperative angiogram reveals satisfying exclusion of the aneurysm, without any compromise of the surrounding vessels. Thank you.
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