case_images: PMC9880138_01
case_images: Preoperative CT angiography showed recurrent left ICA-AchA aneurysm and a surgical clip of the previous operation (open white arrow). The yellow arrow points to the AchA main trunk originating from ICA. The white and gray arrows indicate the anterior cerebral artery and ICA, respectively.
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case_images: A computer tomography (CT) angiogram revealed regrowth of the aneurysm to size with a maximum dome diameter of 6.6 mm (Fig. 1).
case_images: After Sylvian fissure dissection, the recurrent aneurysm (open white arrow) and the surgical clip (yellow arrow) were exposed. AchA's main trunk (gray arrow) was detached from the aneurysm (compressed by microscissors), and the AchA main trunk was confirmed to arise from the ICA. Two small AchA branches were also found arising from the aneurysmal dome (white arrow). The two small AchA branches were temporarily occluded for 10 min.
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case_images: AchA's main trunk was detached from the aneurysm dome while performing RSD, but two thin perforating branches were found arising from the aneurysmal dome (Fig. 2).
case_images: The MEP did not change even after 10 min of occlusion and until completion of skin closure. (A; after skin is closed, B: after 10 min of occlusion, C; before occlusion of Ach A branches).
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case_images: MEP monitoring to determine whether it was possible to sacrifice any of these perforators arising from the aneurysmal dome. MEP recording was performed every 1 min with no MEP amplitude change up to 10 min after temporally clipping of the perforators (Fig. 3). And MEP did not change until skin was closed (Fig. 3).
case_images: DWI-MRI revealed a new ischemic brain lesion at the uncus of the left AchA territory 1 day after surgical clipping (A). CTA demonstrated complete aneurysm obliteration and a healthy patency of the AchA main trunk (B, yellow arrow).
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case_images: Although postoperative diffusion-weighted images (DWI) on magnetic resonance imaging (MRI) showed hyperintensity signals at the medial side of the uncus (Fig. 4A), the patient remained asymptomatic and was discharged home with a modified Rankin Scale of 0. Postoperative CT angiogram showed complete aneurysm obliteration and patency of the AchA main trunk (Fig. 4B).