PICA Aneurysm: Neck Tear-Cotton Clipping Technique

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This video is a nice demonstration of the use of cotton-clipping technique for clip ligation of small aneurysms that are associated with a neck tear. In this case, a posterior inferior cerebellar artery aneurysm. This is a 52 year-old female who presented with subarachnoids hemorrhage and three millimeter left sided PICA aneurysm. The distribution of hemorrhage, and the location of the aneurysm as apparent here is PICA vertebral artery. The aneurysm is more on the side of the PICA rather than the vertebral artery. Patient underwent a left-sided lateral suboccipital craniotomy. Here is the 11th cranial nerve, PICA proximal vertebral artery and the aneurysm. I initially attempted to place an angled fenestrated clip parallel to the axis of the parent vessel. However, this clip configuration would have compromised the 12th cranial nerve. Either for settled on a straight clip perpendicular to their parent vessel. Here is again, a more clear demonstration of the neck of the aneurysm. I'm not in favor of using the clipper application perpendicular to the parent vessel. This method can lead to intraoperative rupture or neck tear, or even dark ear remnant of the neck. In this situation, I attempted to reposition the clip, however, the first clip must have weakened the neck of the aneurysm upon its collapse. You can see the dissection of the aneurysm led to its premature rupture, at the lower of the neck. A piece of cotton, which is quite absorbent, was used to tamponade the bleeding from the neck. While I place this straight fenestrated clip across the cotton and the neck of the aneurysm to preserve their small caliber PICA. Since this aneurysm was very small, the cotton and a single clip were adequate to completely collapse the aneurysm neck. Fortunately, the PICA was preserved in this case, despite its very small caliber, here you can see it's petency and the postoperative angiogram confirmed complete exclusion the aneurysm without any compromise of the surrounding vessels, thank you.

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