October 28, 2019
This is another video describing the methods to assure complete ligation of a posterior communicating artery aneurysm. This is a 51 year old female who presented with acute subretinal hemorrhage, a sided PCoA aneurysm was recognized. You can see the location of the aneurysm in relationship to the entered cranwood process the reconstruction of the 3D CT angiogram demonstrates again the lobulated nature of the aneurysm. Let's go ahead and review the intraoperative findings patient underwent at right-sided frontotemporal craniotomy. The anterior limb of the Sylvian fissure was dissected. The cradial artery at the level of the skull base was recognized. We'll go ahead and cover the brain with a thin cotton white mobilizing the frontal lobe and identifying the aneurysm and dislocation. Here's the proximal neck PCoA is located right there. We have to do a circumferential dissection to make sure the pathway for the clip blades are readily available. We'll go ahead and now work on the distal neck, making sure their circumference of the neck is well exposed. We'll go ahead and use a temporary clip to decrease the turgor on the aneurysm dome. So the neck can be more readily manipulated. Getting the more ufology of the aneurism is more apparent The PCoA is relatively sizable. Most likely a fetal PCoA common in this case. Third nerve, Go ahead and dissect distill the neck aneurysm, Making sure the intracranial artery that is at the tip of my arrow. And under the dissector is well dissected away from the neck of the aneurysm. You can see the intracranial artery is relatively adherent to the neck in this area. Fair amount of this section is being continued. As you can see, the temporary clip really helps with decompression of the sack and it's safe manipulation. Here's the initial attempt. This is relatively attentive clip just to gather the aneurysm. So I can dissect more along it's distill neck. Okay, we want to make sure the neck is very well dissected before a serious attempt at clipping is undertaken. You can see the tip of clip and intracranial artery PCoA or approximately Now that the aneurysm is more decompressed with a clip, I can dissect more distally and identify the residual neck at the tip of the arrow. I'll go ahead and reposition the clip. Also gathering the residual neck. And you can see the intracranial is patent and out of the way of the clip blades, I don't see any residual neck at the tip of the clip. I'm relatively satisfied with this clip construct. All the vessels appear patent PCoA is also patent and unaffected by the tip of the clips. Here's the intracranial artery and the postoperative angiogram demonstrated complete exclusion of the aneurysm without any compromise of the intracranial artery or PCoA. And the postoperative CT demonstrates no evidence of ischemia and this patient made an excellent recovery. Again, this video demonstrates the techniques for dissecting an adherent neck to intracranial artery, as well as using the tentative clip to decompress the aneurism while allowing additional dissection around the distal neck of the aneurysm of course, temporary occlusion of the parent vessel is necessary during tentative clip placement so that any mature intraoperative rupture does not occur. Thank you.
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