PCoA Aneurysm: Minimizing the Risk of Clip Displacement

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This video describes the pitfalls associated with clip ligation of PCoA aneurysms perpendicular to the ICA. It's best for these aneurysms to be clipped as parallel as possible to the long axis of the ICA. This is a 51 year old female who underwent or suffered from a previous hemorrhage from another aneurysm, but also harbored a small left sided PCoA aneurysm. You can see the morphology of aneurism is relatively small, but very broad base incorporating the origin of the PCoA. She underwent to left frontotemporal craniotomy. Here is the initial operation. A subfrontal approach was used. The optic nerve was recognized. The ICA was reached. You can see again the temporary clip on the ICA, the optic nerve, the location of the aneurysm. Straight clip was placed across the neck of the aneurysm while sparing the origin of the PCoA. However, this perpendicular clipping technique, especially in such a small aneurysm using a small clip can lead to delayed displacement of the aneurysm. Here's the clip light, origin of the PCoA. The aneurysm appears to be relatively well clipped. The PCoA is patent. Intraoperative, ICG reveals patency of the PCOM and relative good exclusion of aneurysm dome. And in this case, the entire sack was not recognizable or visualized on the postoperative angiogram. The clip appeared completely off of the neck of aneurysm, which is unfortunate. Patient underwent reopening of her craniotomy. Again, you can see the entire aneurysm is now not clipped and not within the blades. So the old clip light was removed. And this time I should use an angled fenestrated clip to fenestrate the ICA and leave the PCoA origin open. This parallel clip in technique, again, parallel to the long axis of the IC is quite effective to avoid delayed displacement of the clip. The PCoA is also patient. And the postoperative angiogram in this case demonstrated the desirable finding of exclusion of the aneurysm sack without further displacement of the clip, and this patient recovered from her surgery uneventfully. Thank you.

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