P1 Aneurysm: Cross-Court Clipping
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Let's talk about Contralateral Cross-Court Clip Ligation of Posterior Circulation Aneurysms. This is a 52 year old female who previously underwent coil embolization of a ruptured right-sided PCoA aneurysm. She was also identified with a small She was also identified with as small right-sided unruptured P1 as well as left-sided small PCoA aneurysms. Due to previous history of aneurysmal subarachnoid hemorrhage, she underwent clip ligation of her unruptured aneurysms in a delayed fashion. After exclusion of the ruptured aneurysm via coil embolization. A left sided frontal temporal craniotomy was completed to access this right proximal P1 aneurysm. to access this right proximal P1 aneurysm. An ipsilateral approach can be problematic, as significant brain retraction may be required. Therefore, a left sided pterional craniotomy was completed, so that the right sided proximal P1 aneurysm can be approached through the interpeduncular fossa. Here's the location of incision and the turn of the head. The frontotemporal craniotomy was completed. The optic nerve, the carotid artery, the left sided PCoA aneurysm was immediately exposed. Here's the location of the third nerve and the left sided unruptured PCoA aneurysm. However, the more deep seated aneurysm should be clipped first. the more deep seated aneurysm should be clipped first. I continued dissection within the membrane of liliequist. The perforating vessels of the PCoA were carefully protected. These perforating vessels were untethered from their arachnoid bands, you can see the PCoA. Now you can see the basilar artery, the bifurcation and the P1 Contra laterally in the neck of the aneurysm, you can see the perforating vessel associated with the neck of the P1 aneurysm. The cross-court approach is quite effective in this case, in order to expose the right-sided P1 aneurysm, here is a better identification of the perforating vessel originating from the neck of the P1 aneurysm. The neck is circumferentially dissected. Very favorable anatomy for that cross court approach. A temporary clip was placed across the basilar trunk, so the aneurysm can be further manipulated for definitive clip application. You can see this small working space, just medial to the carotid artery. Here's a better view of the perforating vessels, a long straight clip was used to collapse the neck of the aneurysm, a shorter clip would not have allowed adequate visualization around the blades. Through this very deep, narrow operative corridor, I continue to manipulate the neck, I continue to manipulate the neck, assuring myself that the blades are across the entire neck of the aneurysm. Intraoperative fluorescein angiography demonstrated exclusion of the aneurysm and patency of the perforating vessel. In this case, the ICG was not very revealing. Here, again, you can see the exclusion of the aneurysm and patency of the perforating vessel. Here is the PCoA. Straight clip was placed also across the ipsilateral posterior communicating artery aneurysm, while preserving the origin of the PCoA, which was arising from the neck of the aneurysm, in this case. All the perforating vessels from the PCoA were patent. Postoperative angiogram demonstrated complete exclusion of the Pmon aneurysm. Small portion of the ipsilateral PCoA aneurysm neck had to be left behind to protect the origin of the PCoA. Thank you.
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