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PCoA Aneurysm: Technique for Clip Ligation

October 28, 2019


This is another video describing clip ligation of Posterior Communicating Artery Aneurysm, more specifically, an aneurysm that has ruptured and led to third nerve palsy. This is a 42 year-old female who presented with acute left-sided third nerve palsy. Their 3D CT angiogram demonstrates this sausage-shaped appearance of the aneurysm. There is significant amount of thick blood along the basal cisterns. You can see the neck of the aneurysm is closely related to the anterior clinoid process. Let's go ahead and review the intraoperative findings in this case. Right side of the Frontotemporal Craniotomy, the anterior limb of the Sylvian fissure was dissected. You can see the spring action of the bipolar forceps to open the arachnoid bands. Obviously, this is very challenging in the face of thick subarachnoid hemorrhage. Only the anterior limb of the Sylvian fissures opened. The optic nerve is disconnected from the base of the frontal lobe. All arachno bands are widely opened. Here's again, the arachnoid band, over the more medial aspect of the right optic nerve and the chiasm. Here's the internal carotid artery at the level of the skull base. Here's the arachnoid band, over the aneurysm. Often, there's a thick man in this area of the carotid artery. This is cut parallel to the dome of aneurysm, here is the neck of the aneurysm, clearly apparent. Careful dissection along the circumference of the neck is mandatory, before clip application is considered. Here's the A1, M1, the neck of the aneurysm and dissecting around the medial aspect of the neck. That's the most difficult part of it. This section, making sure proximal control is secured. Under a temporary occlusion of the carotid, now the aneurysm is more relaxed. I can look around the neck more aggressively making sure the anterior choroidal artery is protected. You're going to continue to dissect very effectively so that the clip blades have a very known path. Here's the origin of PCoA, every sizable PCoA that should be protected to encrypt application. You can see the edge of the tentorium here, and close association of the aneurysm to the anterior clinoid process. Here's looking medial to the carotid protecting all the perforators that are quite sensitive. Here's the initial attempt at clip deployment. Again, protecting the origin on the PCoA. You can see the curve clip sliding behind the neck of the aneurysm. Again, nor blind dissection is carried out using the clip blades. You can see there's a little bit of residual neck at the tip of the clip. I'll go ahead and reposition the clip using the left hand. You can see the aneurysm is well mobilized. So adequate visualization is secured along the tip of the clips. I'm relatively happy with this construct, there's no residual neck. Here's the PCoA, just behind the carotid, relatively sizable one. Look for the third nerve. Here's the dome very well decompressed. All the surrounding arteries, including the PCoA appear patent on micro-doppler evaluation. Here's the PCoA as we discussed, ICG demonstrates patency of all the vessels and exclusion of the aneurysm, it's very well decompressed. So the third nerve palsy can recover more efficiently. And then here's the final product, the brain appears very healthy. Postoperative CT did not demonstrate any ischemia or retraction injury and the postoperative angiogram revealed clip exclusion of the aneurysm and patency of the fetal PCoA. Thank you.

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