Surgical Clipping of a Trilobed Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Abstract

Intracranial aneurysm, an abnormal bulging or outpouching of the arterial wall, is a prevalent condition among the global adult population. ^[1-3] With the advancement of techniques and materials, endovascular intervention has become the first-line treatment for intracranial aneurysms in routine cases. However, microsurgical clipping remains irreplaceable due to its advantages, including lower recurrence rates, cost-effectiveness, and a well-established approach to direct vascular reconstruction.^[4-7] We present the case of a 63-year-old woman with a trilobed aneurysm located on the anterior communicating artery. Diagnostic imaging demonstrated a trilobed aneurysm of the anterior communicating artery, posing a significant risk of rupture. We employed a conventional pterional approach. While one daughter sac was managed quickly, the other two presented a significant challenge. Despite repeated attempts with various standard and fenestrated clips, we could not fully occlude the aneurysm without compromising vital branches. Therefore, we intraoperatively modified the clip configuration for the first time. Through meticulous adjustment, we achieved a precise fit that completely secured the aneurysm and successfully reconstructed the anterior communicating artery. For special aneurysms, bipolar electrocoagulation shaping may also be an option, as reported by some neurosurgeons for complex anterior communicating artery aneurysms^[8-9]. However, we have introduced an additional technique-aneurysm clip shaping-to provide another option for surgery. In conclusion, this case demonstrates the successful microsurgical obliteration of a complex ACoA aneurysm. Surgical clipping remains a definitive and durable curative treatment for complex ACoA aneurysms. Informed consent was obtained from the patient for the procedure and publication of this operative video.