Exoscopic Clipping of a Ruptured Posterior Communicating Artery Aneurysm Through a Minipterional Approach: 2-Dimensional Operative Video

Abstract

Posterior communicating artery (PCoA) aneurysms represent approximately 15% to 25% of intracranial aneurysms and carry an estimated risk of rupture of 44%. 1-4 Surgical clipping of PCoA aneurysms bears notable challenges associated with operating in a confined space with limited visualization of deep structures. 1,5 We illustrate the case of a 54-year-old woman who presented with a seven-hour course of intense headaches, vomiting and loss of consciousness. Her neurological examination revealed she had a 4/5 left-sided hemiparesis, a Glasgow coma scale score of 12, and a Hunt and Hess score of 3. A head computed tomography scan without contrast showed subarachnoid hemorrhage in the basal cisterns and Sylvian fissures (Fisher grade 3). Digital subtraction angiography and three-dimensional reconstruction imaging revealed a right bilobed saccular PCoA aneurysm of 4.8 × 5.9 mm projecting anterior-inferiorly. After consideration of her clinical course and aneurysmal features, she underwent a right minipterional craniotomy for exoscopic clipping of the aneurysm neck. The patient tolerated the procedure well, her hemiparesis improved, and she was discharged with a modified Rankin scale score of 1 on postoperative day 3. Exoscopy offered high image quality and expanded 3-dimensional view with digital zoom during the aneurysm repair. 6,7 Although evidence suggests exoscopy is non-inferior to microscopy regarding surgery duration, safety, and outcomes, the capability of providing operator ergonomy during surgery is a worth-noting advantage. 8 IRB and patient consent declaration: This study was exempt from the Institution Review Board because patient consent was granted for the use of clinical information, images, and operative videos. The patient consented to the procedure, and the participants and any identifiable individuals consented to publication of his/her image.