Small PCoA Aneurysm: Intraoperative Rupture

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This short video describes the tenants for management of premature intraoperative rupture from a small posterior communicating artery aneurysm. This is a 36 year old female who presented with, acute subarachnoid hemorrhage. Angiogram demonstrated the presence of this small PCoA aneurysm associated with a dominant and fetal posterior communicating artery. The patient underwent a right frontotemporal craniotomy. You can see the internal carotid artery. The frontal lobe was gently elevated. Premature rupture was encountered with minimal manipulation of the carotid artery. Initially, I thought the hemorrhage is originating at this location. However, further inspection revealed, this vascular structure to be the origin of the anterior carotid artery. This is why so important, for the surgeon, to remain composed and make well thought out decisions, during the important moments of surgery. Location of the neck is actually more proximal. I suspect that this finding based on preoperative imaging. I'd quickly dissected around the neck of aneurysm here to assure that the clip lights can be passed. Around the neck of the aneurysm, safely, more bleeding was encountered. I asked for further assistance for clearance of the blood. Using the larger suction, straight clip, was used to clip the aneurysm. While preserving the posterior communicating artery origin. Here's a straight clip. It was passed right around the neck of the aneurysm and the bleeding was immediately controlled. Postoperative CT excluded any evidence of ischemia and the angiogram revealed the desirable findings of the exclusion of the aneurysm and the patient recovered from her surgery, satisfactorily. Thank you.

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