PMC6350030_01
The patient's 3D rotational angiography (3DRA) taken before surgical clipping showed four aneurysms:ACoA (white arrow), Lt. AChA (arrow head), Lt. paraclinoid internal carotid artery (ICA) (black arrow), and Lt. posterior communicating artery (PCoA) (dotted arrow) (A) and schematic drawing of aneurysm clipping in the first operation (B). Pseudoaneurysm (*) was observed immediately adjacent to the clipping site by 3DRA (C, D). Aneurysmal neck (arrow), tear point (arrow head).
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F1
One month prior, she had undergone surgical clipping of a 1.2-cm-sized unruptured ACoA aneurysm and a left anterior choroidal artery (AChA) aneurysm through the left supraorbital keyhole approach (Fig. 1A). During the operation, there had been a small tear and bleeding at the junction of the aneurysm neck and right proximal A2, which had been controlled with clipping at the tear point (Fig. 1B). Cerebral angiography showed a de novo formation of the pseudoaneurysm at the previously clipped tear point (Figs. 1C and 1D).
Intra-operative images of A3-A3 side-to-side anastomosis (A, B). Postoperative 3DRA (C) and digital subtraction angiography (DSA) (D) showed filling of both the ACA branches (arrows) through the bypass (arrow head).
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F2
A1 and no clippable leaflet around the pseudoaneurysm. Alternatively, bypass between the distal ACAs and trapping of the ACoA harboring the pseudoaneurysm was planned. As the superficial temporal artery was too small to perform a microanastomosis between the cortical ACA and the superficial temporal artery, side-to-side bypass between the bilateral pericallosal arteries was performed through a right interhemispheric approach (Figs. 2A-2D).
Schematic drawing of trapping in the second operation of the pseudoaneurysm (A). Pseudoaneurysm was completely obliterated (B).
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F3
ACoA was done through the previous supraorbital corridor. After several attempts of clipping, the ACoA segment harboring the pseudoaneurysm was clipped with a fenestrated clip, with an additional clipping at the right proximal A2 segment to ensure the segment flow arrest, preserving perforators around the ACoA (Fig. 3A). ACoA pseudoaneurysm and the restored bilateral distal ACAs (Fig. 3B). After the rescue surgery and management of the subarachnoid hemorrhage, a moderate degree of neurological sequelae remained (cognitive dysfunction without focal neurologic deficit).