Let's discuss clip ligation of complex aneurysms, and more specifically, a recurrent PICA aneurysm after clip ligation and multiple coil embolizations. This is a 52-year-old female, whose left-sided PICA aneurysm was clipped, approximately, 10 years ago after rupture. This aneurysm continued to recur and underwent at least two embolization episodes, due to its recurrence. On the 3D Angiogram you can see the previous fenestrated clip placed across the neck of the aneurysm. The recurrence has occurred proximal to the clip, just at the junction of the vertebral artery and the origin of the PICA. The presence of the coil material at the distal dome where the aneurysm is also present. The operative stature would involve exposure of the vertebral artery, identification of the distal PICA, as well as the proximal PICA, and ultimately isolating the neck of the aneurysm, just close to the clip blades. Let's go ahead and review the events of the surgery. The patient was placed in a lateral position and the previous "S" incision was used to expose the contents of the sterile parting angle. You can see the extensive amount of scarring that is present here, is the 11th cranial nerve that is followed. Here's the clip that is exposed early during the dissection process due to thick scar. Sharp dissection was the only way to expose the structure safely, here's the vertebral artery that is pursued more distally, here are the lower Cranial Nerves. Dissection is pursued just medial to the blades of the previous clip. This is the brain stem that is being mobilized away from the clip blades. Sharp dissection was continued just medial to the clip to avoid any injury to the brain stem. You can see the exposure of the vertebral artery just proximal to the aneurysm neck. Again, the cranial nerves are carefully protected, dissection is pursued more distally until more of the distal PICA is apparent and its route is identified so it can be followed more proximally to its immediate origin. From the vertebral artery , here is the more proximal portion of the PICA that's adherent to the duro, here is the distal vertebral artery that is present, and here is the aneurysm dome. You can just, immediately next to the blades of the previous clip. Here is, again, a more proximal portion of the PICA. The aneurysm dome was mobilized, it is just lateral to the brain stem. Here's the proximal neck of the aneurysm, here's the distal neck. A clip blade, straight one, was placed to occlude the aneurysm neck effectively. The blades were carefully and gently closed under temporary occlusion of the vertebral artery. Let's review the anatomy one more time, here is the vertebral artery , here's the neck of the aneurysm, here's the PICA, here again is the vertebral artery just proximal to the aneurysm curving more laterally and ultimately, medially. Postoperative cerebral arteriogram demonstrated complete exclusionary aneurysm, this patient suffered from temporary swallowing difficulty, which resolved within three weeks. Thank you.
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