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PCoA Aneurysm: Basic Techniques for Clip Ligation

October 28, 2019


Here's another video describing the basic techniques for clip ligation of a standard posterior communicating artery aneurysm. This is a 32 year old male who presented with subarachnoid hemorrhage. However, he presented a few days after his initial severe headache. You can see the location of the aneurysm. A very standard posterior communicating artery aneurysm. Left-sided frontotemporal craniotomy was carried out. Interlimb of the Sylvian fissure was opened. The thick arachnoid band was dissected all the way toward the carotid artery and optic nerve. You can see the thick clots around the aneurysm. The clot in this case was quite fibrous, consistent with a more delayed presentation of the patient. Here's the clot over the aneurysm. I continued to stay on the carotid artery wall until the neck is exposed. I avoid the dome as much as possible during the early stages of dissection. The thick clot requires sharp dissection. Temporary clip was placed across the proximal carotid. Now I can more aggressively dissect the aneurysm neck, which is apparent here at the tip of the arrow. Here's the distal neck. Staying close to their neck and not closer to the dome. Can see the thick clot, more proximal neck here. Using sharp dissection as much as possible to avoid traction on the dome. I circumferentially dissect around the neck. So, blind clip placement can be avoided. Now looking for the origin of a PCoA from the neck of aneurysm. Here's the origin of the PCoA, right there. Anterior choroidal is not involved with a distal neck of the aneurysm. Here's looking around the neck of the aneurysm in origin of the PCoA. Important landmarks to identify before deployment of the clip. Here is the straight clip parallel to the axis of the carotid artery, as much as possible. Preserving the origin of the PCoA. I can see the origin of the anterior choroidal from the dorsal or posterior wall of the carotid, origin of the PCoA, all appear patent. The magnified view. We did not use fixed retraction; the brain is very healthy. Postoperative angiogram revealed complete exclusion of the aneurysm and patency of posterior communicating artery. Here, you can see the same results using the CT angiogram. There was no evidence of ischemia from the surgery and this patient made an excellent recovery. Thank you.

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