J Cerebrovasc Endovasc Neurosurg.  2023 Dec;25(4):468-472. 10.7461/jcen.2023.E2022.12.002.

Unilateral approach for bilateral clipping of posterior communicating artery aneurysms in a hybrid operating room: A technical note

• Gómez-Amador JL
• Guerrero-Suárez PD
• Martínez-Anda JJ
• Aragón-Arreola JF
• Castillo-Matus A
• Marian-Magaña R
• Sangrador-Deitos MV
• Hernández-Hernández A
• Delgado-Jurado EJ
• Villagrana-Sánchez RS
• Gallegos-Pedraza A
• Diaz-Espinoza JL

• KMID: 2549454
• DOI: http://doi.org/10.7461/jcen.2023.E2022.12.002

Abstract

Bilateral posterior communicating (pComm) artery aneurysms represent only 2% of mirror intracranial aneurysms. Usually, these are surgically approached through bilateral craniotomies for clipping. We present the case of a 50-year-old female presenting with headache and horizontal diplopia. Neurological examination revealed a left oculomotor palsy, with no other neurological deficits. Imaging studies revealed bilateral aneurysmatic lesions in both internal carotid arteries (ICA). A conventional left pterional approach was planned in order to treat the symptomatic aneurysm, and, if deemed feasible, a contralateral clipping through the same approach. The procedure was performed in a hybrid operating room (HOR), performing an intraoperative digital subtraction angiography (DSA) and roadmapping assistance during dissection and clipping. Transoperatively, a post-fixed optic chiasm was identified, with a wide interoptic space, which allowed us to perform the contralateral clipping through a unilateral approach. This technique for clipping bilateral pComm aneurysms can be performed when the proper anatomical features are met.

Keyword

Intracranial aneurysm; Bilateral; Hybrid operating room; Posterior communicating artery

Figure

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  Fig. 1. Preoperative DSA showing bilateral pComm aneurysms. (A) Right pComm aneurysm. (B) Left pComm aneurysm. White arrows representing the location of both aneurysms. DSA, digital subtraction angiography; pComm, posterior communicating

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  Fig. 2. Artist drawing illustrating the post-fixed optic chiasm and a wide interoptic space, allowing a complete view of the neck of the contralateral pComm aneurysm. pComm, posterior communicating

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  Fig. 3. Contralateral pComm aneurysm clipping. (A) Operative view. 1. Left ICA. 2. Contralateral aneurysm clip. 3. Right ICA and right aneurysm neck. 4. Left ICA bifurcation. 5. Right optic nerve. 6. Left optic nerve. (B) Artist drawing illustration of the contralateral pComm aneurysm clipping. pComm, posterior communicating; ICA, internal carotid arteries

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  Fig. 4. Ipsilateral pComm aneurysm clipping. (A) Operative view. 1. Ipsilateral pComm aneurysm’s dome. 2. Ipsilateral clip. 3. Contralateral clip. 4. Left ICA. (B) Artist drawing illustration of the ipsilateral pComm aneurysm clipping and the contralateral pComm aneurysm clipped before. pComm, posterior communicating; ICA, internal carotid arteries

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  Fig. 5. Postoperative DSA. (A and B) White arrows showing both pComm aneurysms clipped successfully. DSA, digital subtraction angiography; pComm, posterior communicating

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