Management of Difficult Intraoperative Aneurysmal Hemorrhages

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Management of high flow intraoperative hemorrhages from aneurysms at the level of the proximal internal carotid artery can be quite challenging. This video describes the case of a 26-year-old female who presented with a strong family history of multiple cerebral aneurysms in a number of her immediate family members. She suffered from a very severe acute headache, and on the CT scan was noted to have subarachnoid hemorrhage within the interhemispheric space and Sylvian fissures proximally, and there was also evidence of mild hydrocephalus. The CT angiogram demonstrated at least two aneurysms, one at the level of the anterior communicating artery and a larger one at the level of the ophthalmic artery. Due to the pattern of the hemorrhage, I suspected that the anterior communicating artery was most likely the cause of the hemorrhage. Shunt went to right-sided front temporal craniotomy for clip ligation of both ophthalmic artery aneurism as well as the anterior communicating artery aneurysm. This is the right sided, subfrontal approach after a pterional craniotomy. You can see that this is the frontal lobe. This is the area of the anterior clinoid that has been slightly drilled away. This is the ophthalmic aneurysm. This is the roof of the orbit, and the neck was exposed and the internal carotid artery was available for proximal control, as I suspected that the ophthalmic aneurysm would be very proximal at the level of the skull base. Obviously an intradural clinoidectomy was necessary in this case to be able to get the proximal neck of the aneurysm exposed. During the process of removing the clinoid extradurally, unfortunately, the bone-removing device caused injury to the aneurysm, which led to torrential bleeding. Let's go ahead and watch as the case unfolds here. I believe that this device became hot at some point during the dissection and adhered to the dome of the aneurysm, which led to bleeding. At this juncture, the best approach is to remain calm and use a piece of cottonoid and cover the area of the bleeding over the aneurysm, as this bleeding site is most likely focal and can be controlled with gentle tamponade and a piece of cottonoid. This piece of the video has been under-edited so the viewers can appreciate events as they unfold. So subproximal over the part of the carotid artery at the level of the neck has been obtained by now. You can see the cottonoid is quite effective with a gentle amount of tamponade. A distal clip was also placed as was as proximal control at below the neck, but I continued to get fair amount of bleeding from the aneurysm and continued to look for other feeding vessels into the aneurysm. As you can see, posterior communicating artery was also clip-ligated, which was very dominant in this case. At this juncture, I attempted to close the bleeding point on the aneurysm to be able to achieve a relatively clean operative field. I closed the area of the bleeding with one straight clip, as you can see here, just at the level of the skull base, and by just adjusting the clip and being patient, I was able to reconstruct the carotid artery as the clip was closing. The rest of the aneurysm was closed with a right angle clip. Intraoperative indocyanine green angiography demonstrates patency of the internal carotid artery with very minimal or no residual aneurysm. I was satisfied with a clip reconstruction of this aneurysm and subsequently diverted my attention toward the anterior communicating artery aneurysm. In this case, after proximal control was secured over A1, unfortunately, I also ran into intraoperative bleeding from the anterior communicating artery here, and this is where I placed a proximal control clip over the proximal A1, and the clip on the ACoA aneurysm was repositioned to assure complete exclusion of the aneurysm and control of the bleeding. Here's again two temporary clips on the bilateral A1s, reposition of the straight clip on the ACoA aneurysm. And this is an intraoperative angiogram demonstrating almost complete exclusion of the ophthalmic artery aneurysm, and a nice clip obliteration of the anterior communicating artery aneurysm. This patient made a very good recovery from her subarachnoid hemorrhage and surgery. Her five-year angiogram has not demonstrated any recurrent or new aneurysms at this time. Thank you.

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