Superior Cerebellar Artery Pseudoaneurysm: Intraoperative Rupture

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This is the case of a troublesome Superior Cerebellar Artery Pseudoaneurysm, associated with a cerebellar artery venous malformation. This is a 56 year old male who presented with very diffuse and dense subarachnoid hemorrhage on the CT scan. You can see the thickness in their widespread distribution of the subarachnoid hemorrhage and the CT angiogram demonstrated potentially a malformation located here and sub vascular abnormalities present within the Intrepid ocular systems angiogram was obtained. Again, you can see the malformation on the AP poster circulation injection angiogram. There is also a fusiform aneurysm associated with a branch or the larger branch of the superior cerebellar artery. This is the posterior cerebral artery and normal branch of the superior cerebral artery and the effected branch of the superior cerebral artery. The aneurysm is very dysmorphic, most likely a pseudoaneurysm. And I did not expect to find a very robust wall inter-operatively. However, my attempt during surgery was to get as close to the neck of the aneurysm on the SCA as possible to potentially preserve some of the perforating vessels at the origin of this second SCA. Let's go ahead and review the inter-operative findings, left front temporal craniotomy was completed. The anterior limb of the Sylvian fissure was dissected. Here's the optic nerve, Third nerve. The oculomotor carotid triangle was accessed. A member of Lily quest was dissected, a thick amount of clot was encountered. Here's the basle artery. I try to dissect within the clot to be able to find the origin of the second SCA aneurysm. I'm sorry the origin of the second SCA. However, during the dissection torrential bleeding was encountered. Obviously visualization is quite limited. Here's the point of bleeding, further manifestation led only to a more bleeding from the aneurysm. You can see this dysmorphic vessel leading to the aneurysm. First, I attempted to coagulate this vessel. However, this was not successful. I understood that I just have to grab the more proximal length of the SCA and quit elated to stop the bleeding. Dynamic retraction of the quartered artery was applied. You can see the bleeding is quite brisk after come across the entire pathologic artery to be able to occlude it completely. I was finally able to do so. I was trying to stay as far as possible away from the bachelor artery. The bleeding is mainly controlled, there was some slight amount of bleeding. I'm sorry, the bleeding was mainly controlled. However, there was slight amount of bleeding from the wall of the basilar artery, piece of cotton was used to cover this small bleeding point and that source of bleeding was controlled immediately. Postoperative angiogram revealed complete exclusion of the pathologic SCA branch as demonstrated here. Obviously the AVM remains present and the postoperative CT scan revealed no significant evidence of ischemia. This patient eventually made a nice recovery. Again, pseudoaneurysm obviously lack a robust wall and control of bleeding is best achieved by occluding the proximal segment of the vessel. In this case, torrential bleeding was encountered at the depth of our dissection and the most important rule is to stay in control, keep the operative field clean and find just the right location where permanent ligation of the artery will lead to control the bleeding. Thank you.

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