Orbitozygomatic Craniotomy for Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Area of Science:

• Neurosurgery
• Vascular Neurology
• Surgical Technique

Background:

• Giant intracranial aneurysms, particularly those in the anterior communicating artery (ACoA) region, pose significant surgical challenges.
• Difficulty in achieving adequate visualization of the parent artery and aneurysm neck complicates surgical management.
• Incidental identification of such aneurysms necessitates careful surgical planning and execution.

Purpose of the Study:

• To describe a surgical technique for managing a giant anterior communicating artery aneurysm.
• To highlight methods for improving visualization and achieving secure aneurysm neck occlusion.
• To present a case demonstrating successful surgical intervention for a complex intracranial aneurysm.

Main Methods:

• Orbitozygomatic craniotomy for aneurysm exposure and neck dissection.
• Aneurysm dome opening and thrombectomy for debulking and enhanced visualization.
• Sequential application of temporary clips to bilateral A1 and A2 vessels to control hemorrhage during thrombectomy.
• Application of permanent clips to the dissected aneurysm neck for occlusion.
• Use of cotton and a fenestrated clip for hemostasis of a small aneurysm neck fracture.
• Intraoperative indocyanine green (ICG) fluoroscopy to confirm parent and distal vessel patency.

Main Results:

• Successful debulking of the giant aneurysm via thrombectomy facilitated neck visualization.
• Controlled hemorrhage during thrombectomy through temporary clipping of bilateral A1 and A2 vessels.
• Secure occlusion of the aneurysm neck achieved with multiple permanent clips.
• Hemostasis successfully maintained using cotton and a fenestrated clip for a neck fracture.
• Verified patency of parent and distal vessels using ICG fluoroscopy post-clipping.

Conclusions:

• A combination of orbitozygomatic craniotomy, aneurysm thrombectomy, and meticulous clipping is effective for managing giant ACoA aneurysms.
• Thrombectomy is a valuable adjunct for improving surgical visualization in complex aneurysm cases.
• ICG fluoroscopy is essential for confirming vascular patency and ensuring successful surgical outcomes.
• This technique offers a viable approach to address the surgical challenges posed by giant intracranial aneurysms.