The neck of PICA aneurysms, especially the ones that are fusiform or potentially pseudo aneurysms can be quite fragile in younger patients who present with subarachnoid hemorrhage. This is a 30 year old male who presented with acute subarachnoid hemorrhage and fourth ventricular hematoma. You can see the location of the more distal fusiform, or potentially pseudo aneurysm of the PICA. In addition, a superior cerebellar artery aneurysm was noted. However, the presence of that clot within the fourth ventricle led me to believe that the PICA aneurysm was the cause of the bleeding. He underwent a lateral suboccipital craniotomy. no Magna was opened. And a distal, PICA branch was isolated. The tonsils were carefully mobilized. You can see the clot, there is a clot over the area of aneurysm. This aneurysm appear not to have very robust walls and most likely was it pseudo aneurysm. Here you can see only a clot and not really at bonifide wall. Circumferential dissection of the parent vessel was completed. Straight clip was attempted on an angled applier. However, this led to tear at the neck of aneurysm, very close to the lumen of the parent vessel. You can see the aneurysm is essentially every thin blood clot without a robust wall. Despite the slow closure of the aneurysm lights, you can see the tear at the neck of the aneurysm. Pretty much into the lumen of the PICA. I did not feel the cotton clipping technique would be effective here in preserving the lumen of the PICA. A temporary clip was placed proximal to the aneurysm on the PICA for proximal occlusion of the vessel. Adequate visualization was not available. An absorbent piece of cotton can be used to cover the bleeding point, and keep the operative field relatively clear, so microsurgery can continue. Here's the temporary clip occluding there. Distal part of PICA, just proximal to the aneurysm neck since repair of their vessel was deemed not possible. You can see again, the tear into the lumen of the PICA, permanent or definitive proximal occlusion of the PICA proximal to the aneurysm was elected. You can see the temporary clip has been removed, and a permanent clip is applied. The aneurysm was essentially trapped. Luckily in this case, there was supportive retrograde flow through the anterior inferior cerebellar artery. This phenomenon led to absence of any ischemia, despite sacrifice of the distal PICA territory. This patient recovered from his surgery without any new neurological deficits. Thank you.
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