Clip ligation or recurrent or residual aneurysms present a different set of challenges than microsurgery within virgin territories. The first set of challenges is the need for dissecting sharply within the scar around the neurovascular structures and around the neck of the aneurysm, and second technical challenges is mobilization of the previous clip, but not removing it. And also mobilization of part of the dome or the aneurysm within the scar. So that when the new or the second clip is applied onto traction on the dome and surrounding neurovascular structures is avoided based on the presence of the scar. Obviously, the normal anatomical eric nidal and pure planes are significantly obliterated. Let's go ahead and discuss these challenges using the case of a 42 year old female who presented with recurrent or residual right-sided posterior communicating artery aneurysm. She previously underwent clip ligation of her picalm aneurysm in an outside institution. You can see that the clip was applied perpendicular to the long axis of the internal carotid artery and for small aneurysms with broad base, using a short clip perpendicular application can lead to their delayed displacement. Placement of eclipse plates parallel to the long axis of the ICA is most effective for avoidance of residual neck and delayed clip displacement. So in this patient during re-exploratory operation, I placed a fenestrated clips, angled fenestrated clips, and fenestrated the ICA placing the clips parallel to the internal carotid artery. The poster to communicate already was very atretic in this patient, and therefore I felt that it's compromised will not place the patient under risk of schema. A right frontotemporal craniotomy was again performed. The previous bone flap was elevated. You can see the dura was opened in a very unusual fashion, usually open during a curvilinear fashion. This is the roof of the orbit. Here is the latter aspect of the sphenoidal wink. The dura was open parallel to the roof of the orbit and also parallel to the entry aspect the sylvian fissure. I avoided generous opening of the dura to minimize the risk of cortical injury from dissecting the scarred endura to the lateral aspect of the frontal and temporal lobes. So here is the incision with dura, again, parallel to the roof of the orbit and parallel to the introspect sylvian fissure. I opened a dural only where it was necessary. Next, their frontal lobe was gently elevated, and three aspect of the sylvian fissure was dissected. As you can see here, the IC at the level of skull base was exposed. This is the optic nerve. You can see the previous clip within the scar. Again, first challenges. This exuberant scare here is portion of the blister over the domo, the aneurism here's a branch of anterior choroidal artery, here's again the aneurysm, which is relatively right base. Proximal internal carotid artery is exposed. The previous clip is not removed or significantly manipulated as much as possible. Here you can see that blister in arizonae, the surrounding soft tissues are mobilized, the perforating branches along the medial choroidal artery are protected here is to enter a cradle artery evident at the tip of my arrow. Next, the passage way for the eclip blades along the medial aspect of the ICA are dissected. Here's the lateral aspect of our dissection. The clip is left behind, however, disconnected from the surrounding soft tissues. So when I closed in new clip blades onto traction on the dome of the aneurysm, which is next to the previous clip, is avoided. Again, the origin of the anterior choroidal artery here is mobilization of it. Clip blades. You can appreciate the blister aneurysm, again. We're just about ready to bring in the angled fenestrated clip. Additional dissection is continued so that when the clip blades are closed, the new clip blades, again, is surrounding neovascular structures that are at hend to the clip blade are not placed under undue traction. So, obviously the third nerve that is being carefully dissected. Here's the temporary clip. Here's the angle finistered to clip. You can see that blades are parallel to the long axis of the ICA. The origin of the anterior corner artery is protected and the ICA is included within the fenestration or the clip. You can see all the structures that are being mobilized as the clip has been closed. You can see the clip moved completely away from its lateral soft tissues and the third nerve. And this is exactly the reason why the clip and the surrounding soft tissue structures should be released. So when the clip is closed, the structures are not placed under, undo traction, And the dome of the aneurysm is not potentially avulsed. obviously you want to make sure that lumen of the IC is not compromised, both flouricine and ICG, angiograms demonstrate patency of the ICA and complete exclusion of the aneurism, the origin of it. And to chrodid artery was peyton. Here is the, the magnified view of the operative corridor. Post operative cerebral angiogram demonstrates complete exclusion of the aneurism without any complicating feature. Thank you.
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