Clip reconstruction of a giant internal carotid artery bifurcation aneurysm in hybrid operating room: 2-Dimensional operative video

Abstract

Giant internal carotid artery (ICA) bifurcation aneurysms are technically difficult to treat because of lack of a definable neck, which makes direct clipping impossible. In addition, these lesions are related to multiple perforating arteries, posing a different challenge to surgical operators. This video demonstrates clip reconstruction of a giant ICA bifurcation aneurysm in a hybrid operating room. A 32-year-old female presented with dizziness for one year. Angiography demonstrated a giant left ICA bifurcation aneurysm. The patient was consented for both clip reconstruction and extracranial-intracranial bypass if needed. A left pterional craniotomy was performed. After dural opening, the sylvian fissure was opened widely until the aneurysm was identified. The proximal ICA was then identified. The aneurysm projected posteriorly, involving the origins of both the A1 and M1 segments. After temporary clipping, the critical perforators were dissected free from the aneurysm wall. Tandem fenestrated clipping was used to reconstruct the parent artery. Finally, curved clips were used to occlude the distal part of the neck. Vessel patency was evaluated using intraoperative Doppler and indocyanine green angiography. Intraoperative somatosensory and motor evoked potential monitoring remained unchanged after final clipping. Intraoperative angiography confirmed complete obliteration of the aneurysm and reconstruction of the parent artery. The patient recovered well without any complications. Giant ICA bifurcation aneurysms are complex lesions that require preoperative planning and intraoperative monitoring. Adherence to general principles, including careful dissection of aneurysmal wall from adjacent perforators and clip reconstruction using tandem fenestrated clipping, these lesions can be treated safely and effectively.