Microsurgical Clipping of Ruptured Anterosuperior-Projecting Anterior Communicating Artery Aneurysms: How We Do It.

In anterosuperior-projecting anterior communicating artery (ACoA) aneurysms, the aneurysm dome usually adheres to 1 or both proximal A2 segments, which may present technical difficulties. This video demonstrates microsurgical clipping of a ruptured anterosuperior-projecting ACoA aneurysm. A 52-year-old male presented with a Hunt-Hess grade II subarachnoid hemorrhage. Computed tomography showed subarachnoid hemorrhage in the basal cisterns and sylvian and interhemispheric fissures. Angiography demonstrated a wide-necked ACoA aneurysm projecting anterosuperiorly. Considering the risk of recurrence, the patient decided to accept surgical treatment. The patient was positioned supine, and the aneurysm was exposed via the lateral supraorbital approach. The carotid cistern and optic cistern were opened to release cerebrospinal fluid and achieve adequate brain relaxation. A subpial resection of a small portion of the gyrus rectus was performed to visualize the ipsilateral A2, recurrent artery of Heubner, and base of the aneurysm. A plane was dissected between the anterior aspect of both the A2 segment and posterior aspect of the aneurysm. A straight clip was placed parallel to the ACoA to completely obliterate the aneurysm. Postoperative angiography confirmed complete obliteration of the aneurysm. The patient recovered well without any complications. Successful treatment requires preoperative surgical planning, precise dissection, and preservation of critical structures. With adherence to these general principles, these aneurysms can be treated safely and effectively.