This video describes the technical nuances for clip ligation of a superior cerebellar artery or SCA aneurysm. This is a 32-year-old female who presented with an incidental SCA aneurysm. CT angiogram demonstrates the morphology of the aneurysm and the surrounding vessels. More specifically, the coronal CTA illustrates the projection of the dome and the morphology of the origin of the PCA and the SCA. Very importantly, the neck of the aneurysm is intimately associated with the posterior clinoid process and therefore the working space and the proximal control is expected to be challenging during the operation. Here's a cerebral arteriogram illustrating the very broad base of the aneurysm. And the fact that the SCA itself is originating from the neck of the aneurysm. A left-sided front temporal craniotomy was completed. The frontal lobe was mobilized away from the optic nerve. Sylvian fissure was aggressively dissected. Here, you can see A1, origin of M1 and the bifurcation. The membrane of Liliequist was opened. Aneurysm is exposed. Here's the origin of the SCA, as our trunk origin of the SCA. The dome was released. Here's the origin of PCA, just distal to the neck of the aneurysm. I explored the superior carotid triangle above the carotid bifurcation. This space was very limited and the perforating vessels were obstructive. As you can see, the space is very narrow, restricted. I attempted a number of different clips and different directions of application. Ultimately, I was settled on a curved, angled clip that you will see in a moment. Here's the clip that I was very satisfied with in terms of its angle. Proximal control was very limited. I attempted application of a temporary clip, but presence of the temporary clip, very much restricted application of the permanent clip on the neck of the aneurysm. Therefore, I asked my endovascular colleagues to deploy a balloon within the basilar trunk for proximal control. Upon inflation of the balloon, I was able to deflate the aneurysm just enough so that the aneurysm can be more aggressively mobilized and the neck of the aneurysm more clearly identified. All the perforating vessels were mobilized away from the aneurysm and its neck. Again, moving the aneurysm around, making sure I have a clear idea where the clip blades should be sitting at, especially more laterally, it can be difficult to see the neck of the aneurysm. Here's the neck, origin of PCA. Here's the application and deployment of the final clip. I exercise patience, make sure the clip is deployed just where it needs to go to completely exclude the aneurysm while preserving the origin of the SCA. The blades are spanning the entire neck of the aneurysm. The aneurysm appears decompressed and completely excluded. Postoperative angiogram confirmed final exclusion of the aneurysm with patency of the SCA and PCA. There was no evidence of ischemia and this patient made an excellent recovery and returned to work. Thank you.
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