Large Fusiform PCoA Aneurysms

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This video reviews technical nuances for clip ligation of large PCoA aneurysms, using the intradural clinoidectomy technique. We're gonna use the case of a 46-year old female, who presented with a large 12mm unruptured PCoA aneurysm. As you can see in these imaging studies, this aneurysm is very closely related to the anterior clinoid and has a very broad base, with a smaller daughter aneurysm just inferior to the larger aneurysm. The aneurysm originates from the posher lateral wall of the right internal carotid artery. Go ahead and approach this aneurysm, through a right frontal temporal craniotomy. As you can see in this exposure, this is the distal part of the right internal coratoid artery at its end of bifurcation. This is the right optic nerve and the interclinoid. We'll go ahead and open some of the arachnoid membranes separating the optic nerve from the vascular structures, in order to obtain proximal control over the aneurysm, as well as expose the entire neck of the aneurysm. The dural is open over the ante-clinoid and the ante-clinoidectomy is completed after the clinoid is hollowed out. It is gently mobilized and dissected from the surrounding attachments in to and including the clinoid ligament. Here you is, you can see the tip of the clinoid that was hollowed out and it's being now mobilized, away from the surrounding soft tissues. Some bleeding from the cavernous sinus may be easily controlled using pieces of gel foam soaked in thrombin. Here is the exposure after the clinodectomy has been completed. You can appreciate now the nick of the aneurism more proximately. We opened some of the arachnoid membranes around the dome of the aneurism to mobilize the aneurysm dome without placing too much traction on the dome itself. Here is now the origin of the anterior choroid artery draping over the superior dome of the aneurysm. We'll go ahead and use the retrograde decompression technique. A balloon is placed within the carotid artery at the neck and a distal clip over the carotid artery, just distilled the aneurysm, as well as the retrograde suction through the balloon within the carotid artery in the neck, allows a generous decompression of the aneurysm and placement clips to completely exclude the aneurysm from the circulation. Two clips are placed. You can see ICG angiography reveals good filling of the internal carotid artery and complete exclusion of the aneurysm. In this situation, since the small aneurysm was intracavernous, it was left alone and the postoperative 3D angiogram reveals good exclusion of the aneurysm without complicating feature.

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