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CC BY-NC-ND 4.0 · J Neurol Surg B Skull Base 2022; 83(S 03): e606-e607
DOI: 10.1055/s-0041-1726425
Skull Base: Operative Videos

Clip Reconstruction of a Previously Leaked Large Complex Posterior Communicating Segment Aneurysm with Extradural Anterior Clinoidectomy

Duygu Baykal
1   Department of Neurological Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
Burak Ozaydin
1   Department of Neurological Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
Ufuk Erginoglu
1   Department of Neurological Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
,
Mustafa K. Baskaya
2   Department of Neurological Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, United States
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Funding The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
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Abstract

Fusiform or near-fusiform aneurysms that involve the long segment of the supraclinoid internal carotid artery (ICA) pose significant challenges to neurovascular surgeons. Involvement of the origin of vital branching arteries in this segment may preclude safe treatment with flow diverting stents. In addition, clip reconstruction may also not be possible in this region due to entire or near-entire involvement of the circumference of the ICA ([Fig. 1]). In this video article, we present a case of a complex and previously leaked, (visualized with hemosiderin) aneurysm of the posterior communicating segment of the ICA, in a 60-year-old female. Multiple complexities made this aneurysm challenging to treat. These included (1) a 270-degree encirclement of the ICA with multiple lobulations that left only a small section of nondiseased vessel wall, (2) a relatively short segment of the supraclinoidal ICA that made proximal control challenging thus requiring an extradural anterior clinoidectomy, (3) a fetal posterior communicating artery that originated immediately proximal to the beginning of the aneurysm, and lastly, (4) an anterior choroidal artery that was firmly adherent over the aneurysm dome. In this video, we present the microsurgical steps for dealing with this complex aneurysm, including extradural clinoidectomy and clip reconstruction ([Fig. 2]). Postoperatively, the patient woke up without any deficits. Angiography showed complete obliteration of the aneurysm.

The link to the video can be found at: https://youtu.be/3Zz-ecvlDIc.


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Keywords

complex aneurysm - hemosiderin - anterior clinoidectomy - fetal posterior communicating artery
Zoom Image
Fig. 1 Preoperative axial (A) and coronal (B) computerized tomography angiography, lateral (C) and right anterior oblique (D) digital subtraction angiography (DSA), and three-dimensional (3D) reconstruction (E, F) show a right-sided, large and complex posterior communicating segment aneurysm of the internal carotid artery. Postoperative right anterior oblique (G), and 3D reconstruction (H) show complete clip obliteration of the aneurysm. 3D, three-dimensional.
Zoom Image
Fig. 2 Intraoperative photomicrographs showing the surgical steps. (A) Extradural anterior clinoidectomy. Note the decompressed optic canal and lateral orbitotomy. (B) Arachnoid dissection of the opticocarotid cistern. Optic nerve, superior hypophyseal artery, and the supraclinoid segment of the internal carotid artery (ICA) is visible. (C) Thrombosed part of the aneurysm is visible after completed arachnoid dissection. Note the optic nerve (ON), optic chiasm (OC), ICA, and A1 segment of the anterior cerebral artery. (D) Fetal posterior communicating artery (PCoA) originating from ICA. (E) Hemosiderin is visible over the aneurysm dome. (F) Adherent anterior choroidal artery (AChA) over the aneurysm dome. Instrument tip is at the AChA. Note the lobular appearance of the aneurysm. (G) View of the completely obliterated aneurysm after multi-clip reconstruction. ON, ICA bifurcation, and untethered AChA is visible.

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Conflict of Interest

None declared.

Address for correspondence

Mustafa K. Baskaya, MD
Department of Neurological Surgery, University of Wisconsin-Madison
600 Highland Avenue, CSC K8/828, Madison, WI 53792
United States   

Publication History

Received: 30 April 2020

Accepted: 18 October 2020

Article published online:
08 April 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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Zoom Image
Fig. 1 Preoperative axial (A) and coronal (B) computerized tomography angiography, lateral (C) and right anterior oblique (D) digital subtraction angiography (DSA), and three-dimensional (3D) reconstruction (E, F) show a right-sided, large and complex posterior communicating segment aneurysm of the internal carotid artery. Postoperative right anterior oblique (G), and 3D reconstruction (H) show complete clip obliteration of the aneurysm. 3D, three-dimensional.
Zoom Image
Fig. 2 Intraoperative photomicrographs showing the surgical steps. (A) Extradural anterior clinoidectomy. Note the decompressed optic canal and lateral orbitotomy. (B) Arachnoid dissection of the opticocarotid cistern. Optic nerve, superior hypophyseal artery, and the supraclinoid segment of the internal carotid artery (ICA) is visible. (C) Thrombosed part of the aneurysm is visible after completed arachnoid dissection. Note the optic nerve (ON), optic chiasm (OC), ICA, and A1 segment of the anterior cerebral artery. (D) Fetal posterior communicating artery (PCoA) originating from ICA. (E) Hemosiderin is visible over the aneurysm dome. (F) Adherent anterior choroidal artery (AChA) over the aneurysm dome. Instrument tip is at the AChA. Note the lobular appearance of the aneurysm. (G) View of the completely obliterated aneurysm after multi-clip reconstruction. ON, ICA bifurcation, and untethered AChA is visible.