Medial Complex PICA Aneurysm

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This is another video describing clip ligation of a relatively medial but complex PICA aneurysm where PICA originates from the neck of the aneurysm. This is a 63 year-old female with history of cervical hemorrhage from another aneurysm. 3D reconstruction angiogram demonstrates the morphology of the aneurysm as well as the location of the PICA relative to the neck of the aneurysm. Axial CT angiogram demonstrates the location of the aneurysm, relatively medial and close to the ventral lateral aspect of the brainstem. Let's go ahead and review clip ligation strategies. In this case, a left suboccipital craniotomy was completed. Here you can see C1 located here. Here's the vertebral artery, the 11th cranial nerve. Usually a retractor is necessary just to hold the cerebellum in place if an aneurysm is so medial as present in this case. Patient is in the lateral position. We'll go ahead and follow the vertebral artery to expose the origin of PICA. Here you can see the PICA, the aneurysm. Here's the 12th cranial nerve going around, then I clip the aneurysm. Here's the origin of the PICA, right where the nerve is transversing. Here's further exposure of the aneurysm neck, more laterally in the nerve. PICA from an aneurysm neck. Seems like the neck is relatively well exposed. Here's distal vert going away from us. In this case, since the PICA is relatively high origin, I try to use the tandem clipping technique, closing the distal, then I clip the aneurysm with a straight fenestrated clip and the more proximal one with a curved clip, leaving some space for origin of PICA. In this case, the Doppler demonstrate patency of PICA, however fluorescein angiography demonstrates some filling of the aneurysm in a moment. Here you can see the filling of the aneurysm. I'll go ahead and advance the clip further by using a longer clip blade first. A longer, straight fenestrated clip. Here you can see going all the way with the suction on the brain stem, closing the distal part of the neck of the aneurysm. It looks pretty good at this stage. PICA appears patent. And then I'll go ahead and deploy the curved clip. Again, leaving some space for the origin of PICA through the fenestration of the first clip. And in this case, ICG angiogram demonstrated complete exclusion of the aneurysm here, with preservation of PICA. Here is the final result with an healthy cerebellum and here's the post-operative angiogram demonstrating patency of PICA, no residual aneurysm. The vertebral artery is patent as well, the CT did not reveal any evidence of ischemia and this patient made an excellent recovery. So this video, again, demonstrates the techniques for exposing the relatively medially located PICA aneurysms, as well as the clipping strategies, the tandem clipping technique using a straight fenestrated clip and a curved clip in order to preserve the origin of PICA, where the origin of PICA is relatively on the neck and a little bit distal to the vertebral artery. Thank you.

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