April 29, 2016
The vertebral artery aneurysms can potentially reach a very large size. They're ligation requires special methods that will be discussed here. This is a 58 year-old female, who was diagnosed with an incidental left-sided, 15 millimeter vertebral artery aneurysm, as well as an associated small PICA aneurysm. The morphology of the aneurysm is apparent, is relatively broad-base and this small PICA aneurysm is associated with the neck of the aneurysm. This silver vertebral artery originates from the neck of the aneurysm, anterior to the brainstem. This distal neck of the aneurysm can be quite difficult to see intraoperatively. Let's go ahead and review the operative events for this patient that led to exclusion of these two aneurysms. The patient underwent a left lateral suboccipital craniotomy, or a minimal transcondylar approach. In the lateral position, you can see the incision in a reverse U fashion. The myocutaneous flap is reflected inferiorly out of our working zone. Following completion of the craniotomy, the aneurysm was exposed along the ventral aspect of the brainstem, you can see the lower cranial nerves located at the tip of my arrow. The distal part of the vertebral artery may be apparent. A tentative initial clip was placed collapsed, the neck of the aneurysm so I can see around the neck toward the distal aspect of the neck, where the vertebral artery origin is. The clip was subsequently advanced further, because of the long and white neck of the aneurysm, first the fenestrated clip was used to close the distal neck of the aneurysm, and secondly, a straight clip was used to close the proximal section of the aneurysm. A temporary clip was used on the proximal vertebral artery; however, the contralateral flow from the vertebral artery was quite robust and therefore, a significant deflation of the sac was not possible. Let's go ahead and compare the intraoperative fluorescence angiography methods, the fluorescein as well as ICG. You can see the ICG angiography can be quite limited in the small working space available in the posterior fossa. However, the fluorescein angiography can be more effective. The aneurysm is excluded. All the branching vessels are patent, subsequently a straight clip was also placed across the small aneurysm associated with the proximal neck of the larger vertebral aneurysm. Postoperative cerebral arteriogram demonstrates complete exclusion of both aneurysms. Thank you.
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