January 20, 2016
I would like to share this very disappointing case with you. A case with a very poor outcome. And there are a number of learning pearls involved in this case. This is a case of one of my patients who are suffering from a giant anterior communicating artery aneurysm. She presented with acute onset of confusion and headaches and CT angiogram. A large anterior communicating artery aneurysm is apparent. Importantly, the clot this actually around the posterior aspect of this aneurysm in which is very peculiar to start. I should have most likely concluded that the portion of the aneurysm from that is actually pointing more posteriorly can be the area where the aneurysm rupture had occurred. And this should have led me to believe that manipulation of the aneurysm can be quite risky through clip ligation. As the portion aneurysm that is actually the dome, is very close to the intercommunicating artery complex. Quelling was not deemed very feasible based on the consultation of our endovascular colleagues. As you can see on this 3D angiogram, the neck of the aneurysm incorporates the ACoA complex and the origin of the A2 vessels. Especially on the one to left front temporal craniotomy, the anterior aspect of the Sylvian fissure was exposed and the A1 branches were bilaterally revealed. Here you can see the opening of the lamina terminalis. Here's the ipsilateral A1, the aneurysm and its neck. You can see the dense clot around the more posterior portion of the aneurysm. You can see the A2 branches, the morphology of the aneurysm is now more apparent. You can see the A1, A2 branch on the ipsilateral side. The neck of the aneurysm incorporating the entire ACoA complex. Obviously clip exclusion or the aneurysm can be quite risky and quite complicated. I placed two temporary clips on A1's and deflated the aneurysm with a hope of clip reconstructing the ACoA. One of the potential errors in this case was that the deflation of the aneurysm dome occurred a little bit more closer to the neck then desired. Part of it was really the location of these vessels. As you can see, this is approximately A1, A2, again another A2. And since the hemorrhage, most likely occurred along the posterior part of the aneurism, this initial opening within the aneurysm, as you can see here extended toward the neck of the aneurysm and the ACoA complex. So you can see, here is the rupture side of the aneurism, actually. I attempted to evacuate some of the clot so I can reconstruct the ACoA complex. Some bleeding was encountered this stage. But did not interfere with microsurgery. I placed the fenestrated clip to reconstruct the ACoA, however despite my numerous attempts I was unable to reconstruct the ACoA complex. Therefore additional pieces of clot were removed from the inside of the sack, so a clip can be more appropriately placed despite these maneuvers. The atherosclerosis at the neck of the aneurysm prevented any meaningful reconstruction of the ACoA. Even a distal placement of the fenestrated clip led to complete sacrifice of bilateral A2 branches, as you can see on this intraoperative fluorescein angiogram. Unfortunately, this patient awoke from the anesthesia significantly neurologically compromised. You can see the postoperative MRI demonstrates bilateral A2 infarcts. This is an important case and a learning point about the high risk of these large ACoA aneurysms incorporating the ACoA complex in the origins of the A2 branching vessels. I do not believe clip ligation of these aneurysms is safe or very feasible. Therefore alternative options with consideration of this store of vascularization should be planned. Furthermore, in this case, the aneurysm appear to have ruptured from the posterior aspect of it's dome. Very near the neck of aneurysm, which significantly complicated clip application and led to significant stenosis and compromise of the distal vessels. Thank you.
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