Hunterian LigationWith Distal Revascularization for Management of a Previously Coiled Giant Internal Cerebral Artery Aneurysm: 2-Dimensional Operative Video

Unclippable giant aneurysms pose a significant microsurgical challenge. Options for management are highly dependent on the aneurysm characteristics and cerebrovascular anatomy. Hunterian (proximal) ligation with either high-flow or low-flow distal revascularization is an option for the treatment of aneurysms of the internal carotid artery (ICA). This patient had a multiply recurrent supraclinoid ICA aneurysm following endovascular treatment and progressive ipsilateral homonymous hemianopsia. In preparation for the clip occlusion of the proximal ICA, the patient underwent a balloon test occlusion of the ICA, which had a negative result, indicative of tolerance. A pterional craniotomy was used to perform a low-flow bypass, superficial temporal artery to M2, and clip occlusion of the proximal ICA. The patient tolerated the procedure well with some pressuredependent contralateral symptoms, which resolved. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.