Microsurgical Clipping of Blood Blister-like Anterior Communicating Artery Aneurysm in a Patient with Total Occlusion of Left Internal Carotid Artery Aneurysm.

Blister-like aneurysms represent a rare subtype characterized by a wide neck and dissecting appearance, predisposing them to perioperative rebleeding due to fragile walls. These aneurysms predominantly occur at non-branching sites of the internal carotid artery (ICA). Still, they may also manifest at atypical locations, including the anterior communicating artery (AComA), anterior cerebral artery, middle cerebral artery, posterior cerebral artery, and basilar artery. Treatment of blister-like aneurysms typically involves a combination of microsurgery and endovascular procedures, with no universally established optimal therapeutic approach. Because of the total occlusion of the left ICA and both cerebral hemispheres supply from the right ICA through the anterior communicating artery, we choose microsurgery to avoid thrombotic endovascular complications. Andaluz et al. presented a case series of 5 patients with blister AComA aneurysms who underwent microsurgical intervention. We present a challenging case of a 64-year-old man with thick subarachnoid hemorrhage and total and chronic thrombosis of the left ICA that came with a blister-like AComA aneurysm. This patient underwent microsurgical clipping of an aneurysm (Video 1). In our center, lateral supraorbital craniotomy, described by Hernesniemi et al. is the preferred surgical approach for most anterior circulation aneurysms. Under general anesthesia and in a supine position, the head was fixed using Sugita then the head and shoulder were elevated above to the cardiac level, rotated 30° to the contralateral side, and tilted slightly with some degree of flexion or extension depending on surgical preferences. A curvilinear frontotemporal skin incision behind the hairline was performed. Preserving facial nerve branches, a myocutaneous flap was reflected anteriorly to the superior orbital rim. One bur hole was set below the posterior extension of the superior temporal line and a modified 4 x 4 cm craniotomy was performed using a conventional craniotomy. The sphenoid ridge was drilled off using a diamond bur maximizing the surgical corridor. Dura was opened in a semilunar fashion and reflected anterolaterally. Dissection was started in the basal frontal surface and arachnoid dissection along the optic nerve and the optic-carotid triangle proceeded. We routinely dissected and opened the lamina terminalis posterior to optic chiasma for further cerebrospinal fluid drainage. Wide Sylvian fissure dissection was performed to minimize brain retraction. Sharp arachnoid dissection over the right A1 to AComA complex and optic chiasma was carried out and then proximal control is achieved with a temporary clip. During aneurysm surgery, an intraoperative rupture occurred that was controlled with a temporary clip. Sharp aneurysm dissection and then aneurysm clipping is made under the temporary clip. Six days after the operation, the patient was discharged home without any neurologic deficit.