Anterior communicating artery (ACoA)
aneurysms are prone to
rupture even at smaller sizes. The surgical management of ACoA
aneurysms is highly dependent on the spatial orientation of the saccular projection, categorized as inferior, superior, anterior, or posterior. Superior projecting
aneurysms constitute approximately one-third of all
aneurysms involving the ACoA. These
aneurysms commonly project within the interhemispheric fissure; however, if the
aneurysm is not high-riding, it can often be approached via a transsylvian trajectory. The patient presented after
subarachnoid hemorrhage with a 3-mm superiorly projecting ACoA
aneurysm. The lesion was approached via a right modified orbitozygomatic
craniotomy with a transsylvian trajectory. The
aneurysm reruptured after minimal manipulation of the dome. Mitigation of the intraoperative
rupture was achieved through temporary
clip application to bilateral A1 vessels. Bipolar coagulation and placement of 2 permanent clips facilitated final
aneurysm occlusion. Postoperative imaging demonstrated patent bilateral A2 flow and no residual
aneurysm filling. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.