PMC9479515_01
(a) Cerebral angiography soon after coil embolization (anteroposterior view). A neck remnant is present, although the rupture point is occluded by the coil. (b) Cerebral angiography before direct clipping (anteroposterior view). Expansion of the neck remnant in connection with coil compaction is confirmed. In particular, the part of the coil that formed the loop (black arrow) has undergone major morphological change. (c) Intraoperative photograph of direct clipping. The coil extruded from the aneurysm (white arrow) encircles or strongly adheres to the oculomotor nerve. (d) Intraoperative photograph of the pervious clip readjustment. The previous clip occluding the posterior cerebral artery was moved. Moreover, a mini-clip was added to the suspected remnant portion. (e) Cerebral angiography after the clip readjustment (anteroposterior view). The posterior cerebral artery (paired arrows), which has disappeared before the clip readjustment, is visualized. *Oculomotor nerve,  Posterior cerebral artery,  Superior cerebellar artery,  Aneurysm.
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F1
After embolization, although CAG showed a neck remnant in the aneurysm [Figure 1a], the patient was discharged, with a score of 0 on the modified Rankin scale. The remnant expansion was confirmed in connection with coil compaction [Figure 1b]. Observation of the aneurysm showed that contrary to the preoperative expectation, part of the coil strongly adhered to or encircled the oculomotor nerve, and it was considered that, even if the oculomotor nerve and aneurysm dome were to be dissected, it would be difficult to achieve sufficient mobility of the cerebral aneurysm due to the presence of the coil [Figure 1c]. Postoperatively, CAG was performed while anesthesia was maintained, and it was found that the left PCA could not be visualized; thus, the patient was returned to the operating room for the clip to be applied correctly [Figures 1d and e].