Microsurgical Clip Ligation of Ruptured, Previously Coiled A2-A3 Aneurysm Through Interhemispheric Approach in a...

Previously ruptured aneurysms treated with coil occlusion are at risk of recurrence and require thoughtful strategic planning for adequate aneurysm occlusion.^1-3 Alternative strategies, such as coil extraction or trapping and bypass, are options when simple clipping is not feasible.² A 15-year-old boy presented with a Hunt and Hess grade 4, Fisher grade 4 subarachnoid hemorrhage from a ruptured distal anterior cerebral artery aneurysm. The patient initially underwent coil embolization and craniotomy to evacuate an extensive corpus callosum hemorrhage. Follow-up angiography demonstrated early recurrence of the aneurysm. Subsequently, the patient underwent microsurgical clipping through an anterior interhemispheric approach, while carefully preserving a large venous complex to avoid potentially devastating venous infarction (Video 1).^4-9 In this surgical video, we review the case presentation, surgical anatomy, operative technique, and postoperative course and outcome. We also describe various operative strategies with anatomical illustrations. The patient gave verbal consent for participating in the procedure and surgical video.