October 28, 2019
This is a video describing clip occlusion of a PICA aneurysm and management of massive intraoperative rupture. This is a 42 year female who presented with acute spontaneous intraventricular hemorrhage. Here you can see the CT upon admission and in itself, some blood within the fourth ventricle, making one suspect the presence of a PICA aneurysm. And here you can see the PICA aneurism more based on the PICA side here and relatively multilobulated. You can see the location of the aneurysm relative to the foramen magnum. Relatively minimal amount of bone work is necessary in order for me to reach this aneurysm by lifting up the tonsil. Something that's very important in this imaging modality is that the neck is all the way to the origin of the PICA from the vertebral artery and my clip should span the entire neck for the aneurism to be completely occluded. Let's go ahead and demonstrate the intraoperative finding, again you can see the left side, it's suboccipital approach. Here is C1, foramen magnum. Here you can see relatively minimal bone work, the dura is open, curvilinear along the lateral aspect of the bone work and parallel to it. Paramedian incision was used. Here you can see that tonsil is being mobilized superiorly, and very easily PICA is identified. Here's the vertebral artery, PICA. Go ahead and follow both until we reached the area where they join each other. Temporary clip was used on the vertebral artery. As we get closer to the neck of the aneurysm here, here you can see the aneurysm. Go ahead and dissect around the medial part of the neck in vertebral artery here. Just as I was mobilizing the neck of the aneurysm, some bleeding was encountered. Here you can see the PICA aneurysm vertebral artery. Obviously there is no complete vascular control here because the other vertebral artery is patent and unreachable. So initially I tried to place a fenestrated clip, fenestrating the PICA. However I wanted to see the exact point of bleeding, as you can see here. One has to maintain his or her composure and make sure that clip deployment only includes the neck of the aneurysm and does not compromise any perforators to the brainstem. I tried to use a piece of cotton to control the bleeding, but that didn't prove to be useful. Here you can see the point of bleeding from the aneurysm. Relatively difficult to see exactly where the distal vertebral artery versus the point of bleeding. And every time I try to inspect that area, I just ran into more bleeding. And I trying to control as much of the bleeding possible. Bleeding had become much more fierce as I try to dissect around the bleeding point. At this juncture, it's best for the surgeon to use his or her intuition. Remember that the point of that bleeding is from the aneurysm and the clip blade should come across the entire neck and span the entire neck for the bleeding to halt. And you can see the part of the bleeding, very difficult to see where the distal vertis versus the neck of the aneurysm. Went ahead and used the fenestrated clip, just covering the point of the bleeding, But you can see it's very difficult to see because of the torrential bleeding toward the surgeon. The initial attempt wasn't fruitful. I went ahead and advanced a clip a little bit more, and this time the clip blade spanned the entire neck of the aneurysm and the bleeding stopped. I inspected the dome of the aneurism, PICA making sure none of the perforating branches are compromised. Here is more medial view of the operative field across the neck of the aneurysm. You can see all the cerebrovasculature and cranial nerves are protected and are not included within the clips. Micro-doppler have confirmed patency of the PICA. Final product. In this case, postoperative angiogram demonstrated patency of the PICA, complete exclusion of aneurism. Fortunately, this patient did not suffer from ischemia and made an excellent recovery. Again this video demonstrates the importance of composure, adequately identifying the point of that bleeding. Unfortunately at some juncture or at some point during the surgery, as you try to identify the exact point of the bleeding, the bleeding can become more fierce and massive. However one has to persist, make sure that the neck of the aneurysm is completely dissected and the clip blades are not placed blindly. Blind placement of the clip blades would lead to further cerebrovascular injury and undesirable results. Thank you.
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