Inappropriate Clip Application

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This video describes the inappropriate use and clip deployment across the neck of a broad base ICA aneurysms, leading to Intraoperative Aneurysmal hemorrhage. This is a 66 year-old female who presented with a ruptured 11 millimeter right-sided PCoA aneurysm. You can see the broad base of this PCoA aneurysm. She previously underwent clip ligation of a mirror left PCoA aneurysm a decade prior. A right frontotemporal craniotomy was completed. Before I review the intraoperative events, I want to emphasize the fact that if the clip blades are applied perpendicular to the ICA, rather than parallel, these broad-based aneurysms often resist the entire or complete collapse of their neck leading to intrasaccular hemodynamic changes, which cause premature rupture. This is a video early on in my career. Here's the intraoperative findings. A temporary clip was placed in expectation of placement of the permanent clip. One more time here is the very broad base of this aneurysm. Ideally, an angled finistery clip would be able to close the neck of the aneurysm completely parallel to the very apparent vessel. However, a perpendicular straight clip may not encompass the entire neck of the aneurysm and therefore can lead to partial clipping and intraoperative rupture. A straight clip was used in this case. You'll see in a moment that the clip would not catch the entire neck of the aneurysm. Most likely you see part of the neck is still unclipped. Intraoperative rupture occurred. To control bleeding I placed a longer clip, which unfortunately compromised one of the perforating vessels. I should have removed the initial clip and used an appropriate angled finistery clip to close the neck of the aneurysm parallel to the ICA. Postoperative CT scan demonstrated an anterior choroidal infarct. The patient unfortunately suffered from hemiparesis that although improved slightly, still significantly interferes with her everyday activities. Thank you.

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