Small ACoA Aneurysm: Intraoperative Rupture

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Inappropriate deployment of the clip blades across the neck of the aneurysm, can easily lead to premature intraoperative rupture. Let's review methods to avoid such a complication. This is a 62 year old male who presented with a ruptured four millimeter, superiorly pointing ACoA aneurysm. Imaging demonstrates the small size of the aneurysm, the pattern of subarachnoid hemorrhage, and the dominance of A1 in this part of the circulation, with a projection of the aneurysm, primarily anteriorly and superiorly. Left frontotemporal craniotomy was completed. Small part of the gyrus rectus was removed. Here's the ipsilateral A2. Let's go ahead and review the anatomy in a second. You can see a temporary clip was placed on ipsilateral A1. Here's the ipsilateral A2, contralateral A2, and the contralateral A1 would be just across from the optic nerve. Temporary clip is placed on ipsilateral A1, and neck of the aneurysm is apparent. Again, the aneurysm is pointing anteriorly and superiorly. One of my residents placed the initial clip. You could see that this is a curved clip, and he felt that the clip would close the neck. However, the clip did not span the entire neck of the aneurysm. And if the clip blades do not span the entire neck, the hemodynamic changes within the sack typically lead to a premature rupture. The angle of clip application was not appropriate. At this point, I took over and removed the clip. I repositioned the clip as close as possible to the A1 complex. Bleeding is quite brisk, and despite all the temporary occlusion of A1. Now I bring the clip blades down, flush with the level of ACoA complex, and this maneuver led to exclusion of the aneurysm. Here again is the anatomy of the ACoA complex: contralateral A1, ipsilateral A1, ipsilateral A2, and contralateral A2, with the neck of the aneurysm secured with a clip. Postoperative angiogram demonstrates the desirable results; and this patient recovered well from his surgery. Thank you.

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