Management of a Previously Coiled Anterior Cerebral Artery Aneurysm in a Child: 3-Dimensional Operative Video.

We present the case of an 11-yr-old male who originally presented to an outside hospital with subarachnoid hemorrhage. He was discovered at that time to have a ruptured right A1-A2 junction anterior cerebral artery aneurysm just proximal to the anterior communicating artery. He underwent endovascular coiling at the outside center. While recovering at a rehabilitation center, he had a rehemorrhage and acute neurological decline. He was transferred to our service, where he underwent surgical exploration and clip reconstruction of what appeared to be a pseudoaneurysm. After a frontotemporal exposure, the right A1 segment was identified at the carotid bifurcation and followed medially. The aneurysm was significantly larger than on the original angiogram and the wall of the aneurysm was extraordinarily thin, consistent with a pseudoaneurysm. A small portion of the gyrus rectus was removed to expose the A2 segments and the remainder of the large, partially thrombosed and coiled sac of the aneurysm. Thrombus and the previously placed coils were removed in a piecemeal fashion. Two fenestrated clips were used to reconstruct the right A1, with the blades used to bring together normal tissue on the ventral surface to create a new lumen. A Doppler ultrasound was used to insunate both A1s and A2s to confirm patency. Intraoperative cerebral angiogram showed complete obliteration of the aneurysm and excellent reconstruction of the anterior cerebral complex.The patient did very well and was neurologically intact on discharge.All appropriate patient consents were obtained for this submission.