Multilobulated PCoA Aneurysm: Pitfalls

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Effective clip ligation of multilobulated pcom aneurysms can be challenging because visualization around the posterior wall of the carotid artery is relatively limited. This is a 42 year-old female who presented with subarachnoid hemorrhage. CT angiogram demonstrated a relatively bilobed aneurysm along the posterior lateral aspect of the carotid wall. Here is an axial image. Sagittal CTA image, more definitively defines the morphology of this aneurysm. Patient underwent a left frontotemporal craniotomy. Here's the extent of the exposure. Let's go ahead and review the basics for dissecting the anterior aspect or the anterior limb of the Sylvian fissure for managing proximal ICA aneurysms. First the subfrontal area was dissected and mobilized away from the optic nerve and the optical carotid cisterns were opened and CSF was released. Next I used the inside to outside technique to expose and dissect the anterior limb of the Sylvian fissure. Importantly, the M1 trunk is found and followed more proximally toward the ICA bifurcation. Combination of splitting action of the bipolar forceps and sharply section using micro scissors is quite adequate to atraumatically split the fissure. Here's the M1 trunk and using the inside to outside technique. You can see dissection can be quite challenging in a young patient with evidence of subarachnoid hemorrhage within the fissure. Defined tips of the forceps are used to mobilize the arachnoid bands along with their attached cerebrovascular structures. Can I follow the route of the M1 toward the ICA bifurcation? The M1 provides an excellent roadmap for preserving the pial membranes. Here's a more demagnified view of the limited anterior sylvian fissure split. Here's the proximal ICA at the level of the skull base. Further opening of the arachnoid bands or the optic nerve is necessary. The number six Rhoton dissector was used to further mobilize the subfrontal area away from the optic nerve. Proximal control secured. Here is M1 torturous ICA, which is relatively atherosclerotic. Temporary clip was used. Here's one of the domes of the aneurysm. I suspect to be a smaller one more proximally. The origin of the anterior carotid artery is apparent. Here's one of the domes, smaller dome, more proximally. just on the other side of the suction, here you can see the other dome. This dome should not be confused with the origin of . So one dome here, another dome there, two labials, origin of the is just proximal to the first labial. Let's go ahead and dissect around the neck of the aneurysm more effectively, Again one labial, another labial here, origin of the anterior choroidal. I initially placed this straight clip. I suspect this clip could be relatively short. Let's find out how much of the neck we can cover with the clips. Seen upon collapsing the neck, the more proximal labial is not handled by the aneurysm clip. Along the medial wall of the carotid, you can see the origin of the . Some of the perforating vessels originating from the . There's obviously a nodule or a labial of aneurysm remaining. on the other side of this perforators. Looking more laterally around the carotid wall, you can see the residual dome of the aneurysm over here. The clip was further advanced to encompass the entire neck of the aneurysm. Staying close to the posterior carotid wall, spearing the origin or the here. Think more dissection along the medial neck of the aneurysm is necessary. Let's go ahead and do so. One labial, another labial of the aneurysm. Use a longer clip parallel to the long axis of the internal carotid artery. Appears that the clip is well deployed. Origin of the . Let's go ahead and do an intraoperative ICG angiogram. You can see the more proximal labial still filling at the tip of my arrow. is also feeling So the clip is again short. Just a small lobe of the aneurysm remaining. Clip was further advanced This time and intraoperative angiogram was performed to definitively exclude the aneurysm since visualization was relatively limited in this area. Micro Doppler ultrasound device confirmed adequate paint and seal of the surrounding vessels. You can see that the intraoperative angiogram this time demonstrated adequate exclusion of the aneurysm sacs. Postoperative CT revealed no evidence of ischemia and this patient made an excellent recovery. Thank you.

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