Let's review the general technical nuances for clip ligation of partially coiled aneurysms, and more specifically, an ACoA aneurysm. This is a 62-year-old-female who presented with acute subarachnoid hemorrhage in a poor neurological status. Her aneurysm was not amenable to coil embolization in its entirety, however, the lobule of the aneurysm, that was suspicious in causing the hemorrhage, was embolizable, and therefore this lobule underwent treatment using coiling, and we planned to tackle the rest of the aneurysm using microsurgery, if she made an uneventful, nice recovery. Let's go ahead and review the preoperative images. You can see the pattern of the hemorrhage involving the interhemispheric fissure. This is a multilobulated, anterior communicating artery aneurysm. This very dysmorphic lobe, which was pointing superiorly towards the mass of the hemorrhage, was suspected to be the primary source of the hemorrhage, and this lobule underwent treatment and the rest of the aneurysm was left untreated, as coil embolization of the residual portion of the aneurysm, was deemed too risky, using the coils. She made an excellent recovery. She was returned to the operating room a month later. A left frontotemporal craniotomy was completed. You can see the anteriorly and inferiorly lobe of the aneurysm that was not treated during the initial admission. Here's the lobe of the aneurysm that was treated. Let's go ahead and identify the relationship of these two domes. Here's the dome that is more medial and superiorly projecting. Here's the A1, A2 ipsilaterally. The contralateral A2 is just medial to the ipsilateral A2. I'm defining the neck of the aneurysm more accurately. I wanna make sure, during deployment of the clip, the coils will not interfere with the closure of the blades. Therefore, the relationship of the coils to the neck of the unsecured aneurysm, has to be clearly defined. Here's the A1 artery of Huebner. I'm clearing the pathway for the blades and specifically, the inferior blade of the clip, here. Some of the hypothalamic perforators projecting superiorly and posteriorly. Again, the relationship of the coils to the neck of the unsecured aneurysm is apparent. Here is additional data regarding the anatomical relationships. You can see the dome that was coiled versus that dome that is live. I placed a straight clip initially, to see how much of the unsecured portion of the aneurysm can be excluded. Temporary clip was also placed. Here's the initial result of the clipping. This clip was then repositioned to assure a more desirable exclusion of the sac. Again, the coils tend to push the clip more distally. Obviously, I don't wanna force the clip, and cause a tear at the junction of the coils and the aneurysm sac. A shorter clip was used, just short of the coil mass, to assure better exclusion of the more proximal portion of the sac close to the ACoA. Again, you don't wanna force the coils and fight against them. This appeared to be a reasonable result. Postoperative CT revealed no evidence of ischaemia and good exclusion of the aneurysm without any complicating features, and this patient made an excellent recovery. Thank you.
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