Modified Orbitozygomatic Craniotomy for Clipping of a Ruptured Thrombotic A1-A2 Aneurysm

Ruptured thrombotic aneurysms pose a dual challenge of subarachnoid hemorrhage and local mass effect on neurovascular structures causing cranial nerve palsies or other neurologic symptoms. Although many thrombotic aneurysms can be treated with endovascular techniques, the benefit of surgical treatment of these aneurysms is the fact that clipping can be followed by removal of the clot and decompression of the contents of the aneurysm sac, thereby relieving local mass effect. In Video 1 we present the case of a young man with a ruptured thrombotic anterior cerebral artery (first segment of anterior cerebral artery-second segment of anterior cerebral artery) aneurysm who presented with bilateral vision loss. The aneurysm was clipped via an orbitozygomatic approach, although an interhemispheric approach could have been an alternative, and the contents of the aneurysm sac, which were compressing the optic apparatus, were removed. The patient remained blind in the right eye after the operation, likely due to the initial subarachnoid hemorrhage being directed into the optic nerve. He did, however, have improvement of vision in his left eye. Microsurgical clipping of thrombotic aneurysms allows for exclusion of the aneurysm from the circulation, thereby protecting the patient from repeated hemorrhage, and simultaneous decompression of the local mass effect caused by the rapid increase in the size of the aneurysm due to the clot burden.