Right Orbitozygomatic Craniotomy for Clip Wrapping of an A2 Fusiform Aneurysm: 2-Dimensional Operative Video

Area of Science:

• Neurosurgery
• Vascular Neurology
• Medical Imaging

Background:

• Distal anterior cerebral artery aneurysms pose significant rupture risks and higher operative morbidity.
• Fusiform aneurysms, particularly in the A2 segment, present unique surgical challenges.
• Endovascular treatment may be ineffective for certain complex aneurysm morphologies.

Purpose of the Study:

• To describe a novel surgical technique for managing a proximal A2 segment fusiform anterior cerebral artery aneurysm.
• To evaluate the efficacy of clip-wrapping combined with a permanent clip in restoring native flow dynamics.
• To present a case where open surgical management was necessary after failed endovascular treatment.

Main Methods:

• Surgical isolation and mobilization of the fusiform aneurysm within the interhemispheric fissure.
• Application of a Gore-Tex clip-wrapping technique.
• Placement of a permanent clip parallel to the vessel to maintain native flow.
• Intraoperative indocyanine green (ICG) fluoroscopy to assess distal perfusion.

Main Results:

• The combined clip-wrapping and permanent clip technique successfully restored native flow through the aneurysmal segment.
• Intraoperative ICG fluoroscopy confirmed adequate distal perfusion post-intervention.
• The patient tolerated the surgical procedure well.

Conclusions:

• Clip-wrapping combined with a permanent clip is a viable surgical option for complex fusiform anterior cerebral artery aneurysms.
• This technique may help preserve native flow dynamics in challenging cerebrovascular cases.
• Open surgical management remains crucial for aneurysms unresponsive to endovascular therapies.