Let's talk about management of fusiform PICA aneurysms. This is a 45 year-old female who presented with subarachnoid hemorrhage. Also evidence of blood within the fourth ventricle leading one to believe that there is a PICA aneurysm that has ruptured. 3D cerebral angiogram demonstrated this relatively fusiform PICA aneurysm. Also some evidence of atherosclerosis and stenosis, just proximal and distal to the aneurysm. Patient underwent a right-sided lateral suboccipital craniotomy using a hockey stick incision. You can see the extent of bony removal. The thick arachnoid bends over the tonsils are opened. The clot was evacuated and PICA was identified early, as you can see here. The clot was rather tenacious. I continued sharp dissection over the route of PICA until I was able to identify the vertebral artery. You can see the location of the aneurysm neck and the vertebral artery just proximal to it. Temporary clip was placed over the vertebral artery, so that the aneurysm can be dissected more aggressively. It was just medial to the wall of the aneurysm, it was lateral to it. The aneurism incorporates both proximal and distal PICA. Here's another view of the aneurysm and Pomona atherosclerosis, just proximal and distal to the aneurysm on PICA. To be able to place a clip without occluding the lumen of the PICA, I used a small piece of cotton to wrap around the neck of the aneurysm while placing the clip slightly away from the neck of the aneurysm. Cotton allows good closure of the neck without necessarily occluding the atherosclerotic PICA. Here's the final construct. Let's go ahead and do an intraoperative ICG angiogram, it demonstrated patency of the PICA. Occlusion of the aneurysm is also demonstrated, the clip is across the entire neck of the aneurysm. Post-operative CT angiogram revealed complete exclusion of the aneurysm without any evidence of ischemia, thank you.
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