An Anatomy-Guided, Stepwise Microsurgical Reconstruction of a Posteriorly Projecting ICA–PCoA Aneurysm Beneath the Optic Apparatus - A Detailed Operative Sequence

Sep 30, 2026

Posteriorly directed ICA–PCoA junction aneurysms concentrate technical risk at the posteromedial neck where the PCoA origin and perforators sit beneath the optic apparatus. This case report presents a reproducible, anatomy-driven surgical sequence for a ruptured aneurysm, emphasizing a posterior wall visualization strategy and a clip closing line parallel to the PCoA axis. A 62-year-old woman stabilized after subarachnoid hemorrhage underwent staged microsurgical maneuvers with complete angiographic exclusion and preserved branches, followed by an uncomplicated recovery.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages17

Reading Time43 min

AccessFree to download

Abstract

Background

Case Presentation

Conclusions

1. Introduction

Case Report An Anatomy-Guided, Stepwise Microsurgical Reconstruction of a Posteriorly Projecting ICA–PCoA Aneurysm Beneath the Optic Apparatus: A Detailed Operative Sequence Matei S, erban 1,2,3, Corneliu Toader 1,2,3,* and Răzvan-Adrian Covache-Busuioc 1,2,3 Academic Editors: Hung-Chieh Chen and Dong Ren Received: 9 September 2025 Revised: 18 November 2025 Accepted: 27 December 2025 Published: 1 January 2026 Copyright: © 2026 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license. 1 Department of Neurosurgery,“Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania 2 Puls Med Association, 051885 Bucharest, Romania 3 Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania * Correspondence: [corneliutoader@innbn.com](corneliutoader@innbn.com) Abstract Background: Posteriorly directed aneurysms at the internal carotid–posterior communicating artery (ICA–PCoA) junction concentrate technical risk at the posteromedial neck where the PCoA origin and perforators exist beneath the optic apparatus. Our aim was to describe, in a reproducible fashion, an anatomy-driven sequence in the management of a ruptured ICA–PCoA aneurysm that visualized the posterior wall and a closing line parallel to the PCoA axis and which is placed within contemporary practice. Case Presentation: This is a single case study employing predetermined surgical techniques demonstrating a reproducible method of anatomical microsurgery applied to a posterior projecting ICA-PCoA aneurysm. The authors describe a 62-year-old female who was stabilized by nimodipine and aggressive blood pressure control in the systolic range 140–160 mmHg after an aneurysmal subarachnoid hemorrhage. Diagnostic contrast catheter angiography showed a left ICA-PCoA aneurysm of 13.1 × 10.0 mm at the base with a neck of 4.3 mm projecting posteriorly into the carotid–optic cistern. Complete adherence to a protocol of staged techniques was employed for the operation, as detailed below. Step 1: Early cisternal decompression requiring total and immediate relaxation of the temporal lobe, rapidly opening up the carotid–optic anatomical window. Step 2: Circumferential dissection about the neck of the aneurysm permitting definition of the true posteromedial wall and definition of the perforator territories and anterior choroidal territories. Step 3: Brief but effective ICA proximal quiescence (58 s) permitting clipping under direct vision. Step 4: Staged closure of two clips with the closing line of the clips orientated parallel to the axis of the PCoA with maintenance of the diameter of all parent vessels, the origin of the PCoA and the integrity of the perforators. Urgent postoperative digital subtraction angiography (DSA) study showed complete exclusion of the aneurysm with no alteration in flow characteristics, and 3 months later DSA studies again showed permanent obliteration and patency of those branches. The immediate DSA demonstrated complete exclusion of the aneurysm with patent supraclinoid ICA caliber and PCoA ostium, the anterior choroidal artery was preserved; no angiographic vasospasm was identified. The postoperative course was uncomplicated; there was no hydrocephalus, seizure disorder or delayed ischemia. At discharge and three months postprocedure the patient was neurologically intact (Modified Rankin Scale 0) . Non-contrast cranial CT (three months) demonstrated stable clip position and no hemorrhagic or ischemic sequelae. Conclusions: In posteriorly projecting ICA–PCoA aneurysms that are disturbed beneath the optic apparatus, an anatomy-guided strategy—early cisternal decompression, true posteromedial neck exposure, brief purposeful quieting of the proximal ICA and two-clip closure parallel to the PCoA in selected cases—may provide the

FAQs

Why are posteriorly projecting ICA–PCoA aneurysms considered technically high risk?

They concentrate risk at the posteromedial neck because the PCoA origin and perforators lie beneath the optic apparatus, making spatial visualization and preservation difficult.

What is the main goal of the described surgical sequence?

To use an anatomy-guided, reproducible stepwise approach that visualizes the posterior wall and achieves two-clip reconstruction with the closing line parallel to the PCoA axis while preserving parent-vessel flow and perforators.

What were the postoperative outcomes in the reported case?

Urgent and follow-up digital subtraction angiography showed complete aneurysm exclusion with preserved flow characteristics and branch patency; the patient had an uncomplicated course without hydrocephalus, seizures, or delayed ischemia.

Sep 30, 2026

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