Microsurgical Clip Reconstruction of Ruptured Dissecting PICA Aneurysm: 2-Dimensional Operative Video

This case is a presentation of technical tenets for the microsurgical clipping of a ruptured posterior inferior cerebellar artery (PICA) aneurysm (Video 1). The patient described in this case was a 19-year-old male with a history of polysubstance abuse who presented from an outside hospital after being found unresponsive and admitted for a subarachnoid hemorrhage 7 days earlier. Noninvasive vascular imaging completed at the outside hospital showed no clear intracranial aneurysm except some irregularity of left PICA proximally. The cerebral angiogram subsequently completed after transfer demonstrated a left dissecting PICA aneurysm from the anterior medullary segment of the PICA. Endovascular options were considered to be high risk for this patient due to the wide neck of the aneurysm. Stent coiling was not considered the best option given the concern about recent subarachnoid hemorrhage and the need for antiplatelets. This case is valuable to the literature as it illustrates technical steps required for reconstructing an aneurysm with a dissected wall with pseudoaneurysmal formation, the need for early proximal control, and the use of intraoperative adenosine for temporary cardiac standstill.