Real life Pcomm aneurysm surgery

- Do not retract on the temporal lobe! these aneurysms can be buried in temporal lobe and retracting on temporal lobe significantly increases rupture rate
- If you place the clip on and it starts bleeding, do not remove the clip. Clip-on bleeding is usually small/slow and controllable with suction. Clip-off bleeding may be of the uncontrollable, hits-microscope-lens type
- After you place clip on, you can use the bovie on the aneurysm dome to shrink it down, possibly for purposes of better visualizing distal pcomm (which usually comes off ICA posteriorly) or anterior choroidal. If you bovie, make sure someone is irrigating on you so you do not stick to dome. Also, don't use those special spetzler bovies for this, they are way stronger than normal
- Do not bovie an unclipped aneurysm! 1. You are asking for rupture 2. the bovie only works because it makes the tissue shrink down, which will only actually shrink aneurysm dome if the pressure inside is decompressed from a clip.
- You can take the clip off and reposition if you need to
- You have to visualize anterior choroidal before you close to make sure its still patent. Have to.
- If the Pcomm is not fetal, you can sac it, but if you sac you have to take it right at the origin off the ICA, otherwise you risk incorporating perforators into the clip/compressing perforators with clip. Most famous are thalamoperforating arteries, but perforators off pcomm also supply optic tract/chiasm as well as hypothalamus, mammillary body
- If you can't visualize the origin of AChR well and don't want to put a clip on neck and risk taking it, one option is to place a long clip along midsection of aneurysm to shrink it down enough to see around it-- but you have to use a clip long enough to get all the way across the dome; a partial clipping will increase risk of rupture.
- Pcomm aneurysms do not typically require much dissection or retraction, as long as you open sylvian fissure you should not have to retract much on frontal lobe.