Here's a challenging somewhat fusiform proximal PICA aneurysm. This is a 37-year old female who presented with spontaneous subarachnoid hemorrhage and fourth ventricular IVH. The location of aneurysm is apparent on this coronal view of the CT angiogram. Due to the complex morphology of this anuerysm, the patient underwent preoperative arteriogram. You can appreciate the morphology of the aneurysm in relationship to the vertebral artery and the PICA. You can see the aneurysm somewhat incorporates to origin of the PICA in its neck. Here's another view of the PICA, and as well as the aneurysm and the vertebral artery. Patient underwent a right-sided suboccipital craniotomy in the lateral position. Here's the dura of the craniocervical junction, cerebellum. The dura rise mobilize laterally, and the arachnoid bends over the cisterna magna are opened. Subarachnoid hemorrhage is evacuated, and the vertebral artery is found and followed more distally toward the origin of PICA. Here's the origin of the vertebral artery. Here's the 11th cranial nerve. Temper clip was used on vertebral artery. Decreased flow in the artery was confirmed. Mobilization of the cerebellum allowed exposure of the aneurysm and the PICA as demonstrated here. Here's the 11th cranial nerve, is that distal part of the vessel. Subsequently, a finished sturdy clip was used to collapse the neck of aneurysm. This was conducted relatively easily. The clip was further advanced to make sure the entire neck of the aneurysm is excluded. Here's a final view. While the clip lays across the neck of the aneurysm intra-operative flouricine angiography reveal complete exclusion of the aneurysm and patency of the PICA. Intraoperative ICG also confirm the findings based on intraoperative flouricine angiography. Multi-magnified view of our operative corridor and the post-operative angiogram confirmed the exclusion of the aneurysm without any complicating features. Thank you.
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