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PCoA aneurysm and Third Nerve Palsy: Interesting Clipping

October 28, 2019


Here's another interesting video, describing the techniques for clip ligation of posterior communicating artery aneurysms, causing third nerve palsy. Various aneurysm configurations were used in order to achieve a good exclusion of the aneurysm and decompression of the pressure on the third nerve. This is a 33 year old female, who presented with acute Subarachnoid hemorrhage and third nerve palsy. You can see the sausage-shaped PCoA aneurysm here on the right side. Often these sausage-shaped aneurysms are most often associated with third nerve palsy. Right-sided frontotemporal craniotomy. The aneurysm is evident, splitting the fissure. Looking around for their, PCoA along the medial aspect of their carotid wall. You can see the optic nerve. Here's the distal neck. Here's the origin of the PCoA, and the carotid artery at the tip of my arrow. Here's the origin of the PCoA tentorium. The aneurism as well, dissected and ready for, clip application. Temporary clip was placed, in origin of their, PCoA is evident, to make sure it's not included within our clip blades. Good anatomy. I always like to clip these aneurysms Harold to the long axis of the carotid artery. Therefore, a finished rated clip appear to be a good choice. And angled fenestrated clip appeared to be a good choice, Preserving the origin of the PCoA. However, there is some residual aneurysm here, you can see along the distal neck, at the area of the fenestration, the origin of the PCoA, also may have been compromised via this clip. So try to reposition this clip, a couple of times, I did not see a great result. I think the angle of the clip should be more exaggerated to preserve the origin of the posterior communicating artery. And you can see residual neck distally. So most likely the aneurysm is still filling. I went ahead and remove this clip, and we're going to try a slightly longer clip, and see what kind of result we'll see with that. Longer clip was reasonable. However, again, the origin of the PCoA may have been compromised and there's still a residual neck more distally. This clip was also removed. Straight clip was attempted. I should have most likely brought their clips more parallel to the access of the carotid artery rather than so perpendicular, as this most likely grabs part of the aneurysm neck and not all of it, and it should be more residual aneurysm. Medial to the carotid wall that you can see very clearly here. So this configuration did not work very well either. Again, the blood should have come in more parallel to the access of the carotid artery, here is using more angled finished clip, which I often find to be, much better for these kind of aneurysms. Little bit of residual neck distally again, but the origin of PCoA, is protected. Try to reposition the clip a couple of times. Here's the final result here with this clip. Cried it, appears to be patent. I'm happy with this clip configuration. There is no flow within the aneurysm, and I'll go ahead and puncture the aneurysm dome, which appears to be empty in order to decompress the third nerve. And you can see how the angle finished through the clip was a much nicer fit, in order to preserve the origin of the PCoA and exclude the entire aneurysm, along an axis parallel to the axis of the carotid artery. Here's the decompression of the aneurysm. Third nerve. I'll go ahead and look in more carefully here. You can see within the dome of aneurysm, a nervous well decompressed. And here's an Intraoperative angiogram demonstrating complete exclusion of the aneurism, that was performed before we punctured the aneurysm. The PCoA is patent and here's a postoperative CT scan, which demonstrates no evidence of Ischemia. And this patient made an excellent recovery, and a third nerve palsy improved within the next six weeks after surgery. Thank you.

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