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PCoA Aneurysm-Intraop Rupture without Proximal Control

December 22, 2015


This video describes techniques for intraoperative rupture management for clip ligation of a posterior communicating artery aneurysm. This is a 52 year-old female who presented with subarachnoid hemorrhage in a approximately two centimeter right-sided posterior-communicating artery aneurysm, as demonstrated on this 3D reconstruction of this CT angiogram. You see the relatively bulbous nature of the aneurism and its neck across the internal carotid artery. The aneurysm is pointing postural laterally. There's also ample amount of space proximal to the aneurism on the ICA for proximal control. There's seven hematoma within the medial aspect of the temporal lobe, most likely, very adherent to the dome of the aneurysm. The patient presented Hunt and Hess grade two and subsequently was taken to the operating room for a right-sided front temporal craniotomy. The sylvian fissure was open along its sphenoidal segment. You can see some of the MCA branches. Upon entering the optical carotid cisterns the brain of the patient was noted to be very tight and you can see evidence of acute bleeding from the area of the aneurysm. I attempted to place a temporary clip across the proximal IC the skull base. As I suspected acute interoperative hemorrhage without proximal control, you can see the brain is really tighten and resisting and forcing the suction to hold that temporal lobe gently away. A retractor was placed over the sup frontal area to expose the internal carotid artery. This maneuver was also not effective in providing adequate exposure of the ICA. A commando operation, and otherwise tackling the aneurysm directly without proximal control was my only other option to avoid a disastrous complication. A large suction was used to remove the clot and also the acute blood that you can see from the hemorrhage of the aneurysm. After the clot was removed, the aneurysm appeared to be onee more time thrombosed at its dome. Here's the enter a caroital artery across the IC distal to the aneurysm, this is proximal to the aneurysm where pecan should be located. I suspected another acute intra-operative rupture is likely I continue dissection around the neck of aneurism. A temporary clip was placed to deflate the aneurysm and identify the origin of the p-comm and the anterior caroidal arteries that you can see here. Another intra-operative rupture was encountered slightly curved clip was used to collapse the neck of the aneurysm parallel to the long axis of the ICA, as much as possible while preserving the origin of the p-comm. Here you can see the p-comm and its origin. However, the eclipelates continue to slide toward the ICA intraoperative fluorescent angiography, demonstrated patency of the IC and the p-comm without any filling of aneurysm. Here you can see the inter-caroidal artery, despite this finding, when I attempted to deflate the aneurysm, bleeding from the dome of the aneurysm was again encountered. This meant that I needed another clip to completely collapse the neck of the aneurysm and obliterate the sack and ICG angiogram demonstrated complete exclusion of the aneurysm and no further bleeding from the dome. This is a flow 800 ICG analysis, which demonstrates filling of their p-comm, obviously the ICA, however, on the evaluation of the grapht, you can see that the p-comm is very delayed and is actually filling in a retrograde fashion. The flow seems to be adequate. The p-comm is most likely occluded. However, the clip plates were sliding as I placed a clip across the neck. And I did not feel that I can do a better job in terms of preserving the p-comm due to the presence of atherosclerosis at the neck of the aneurysm. The final clip lays were therefore not adjusted. This is the final result. Post operative angiogram demonstrated complete exclusion of the aneurysm the p-comm was sacrificed. However, it was filling retrograde from P1. this patient did not suffer from any new deficits related to the surgery. This video, again, emphasizes the importance of managing intra-operative rupture before proximal control is secured by tackling the dome of the aneurysm, finding the area of the bleeding, securing proximal control and definitively excluding the aneurysm. In this instance, the neck of the aneurysm was quite atherosclerotic and in atherosclerotic aneurysms, the intraoperative fluorescents and geography techniques can be somewhat questionable and therefore penetrating the dome the aneurysm is most effective confirming that the aneurysm is completely excluded. Another clip was necessary in this case to complete the collapsed, the aneurism and the presence of retro grade flow through the p-comm avoided any Ischemia related to the sacrifice of the posterior communicating artery, thank you.

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