PCoA Aneurysm: Intraoperative Rupture

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This is another video that describes the pitfalls during clip ligation of PCoA aneurysms leading to intraoperative rupture. This is a 52 year old female with acute subarachnoid hemorrhage from a five millimeter left sided PCoA aneurysm. You can see the morphology of the aneurysm. Left-sided frontotemporal craniotomy was completed. This is one of the videos earlier in my career, when I used fixed retractors. The anterior limb of the Sylvian fissure was dissected. Here's further extension of the Sylvian split. Here's the optic nerve, left-sided ICA, location of the aneurysm. Some fibrinous material over the neck of the aneurysm. Dissection continued from the ICA toward the neck of the aneurysm. Temporary clip was placed on the ICA at the level of the skull base. Here's the dome of the aneurysm. I should have used higher magnification and dissected the neck more thoroughly. I place the straight clip prematurely. The clip did not capture the entire neck of the aneurysm, and led to some bleeding from the dome of the aneurysm due to hemodynamic changes in the sack related to partial clipping. Clip was repositioned. This maneuver did not help. To grab the entire width of the aneurysm, a second clip was added. To close the entire neck of the aneurysm. This maneuver led to exclusion of the sack. Next, the first clip was repositioned to keep the origin of the PCoA patent. This clip was further repositioned to assure complete patency of the PCoA origin. Interoperative ICG angiogram demonstrates the patency of the PCoA and its perforating vessels. In postoperative angiogram, again confirmed exclusion of the aneurysm, patency of the PCoA without any evidence of ischemia on the post-surgical CT. Thank you.

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