Ruptured Giant Aneurysm of right ICA and Clipping of Aneurysm under total Circulatory Arrest

A 65 years old lady presented us with a severe headache which was found to be due to rupture of a giant aneurysm arising from the right internal carotid artery. Options for this patient included Flow diverter insertion and clipping of aneurysm. After discussion of Pros & Cons with the patient and relatives a decision to clip the aneurysm was taken. An option of Total circulatory arrest was kept to aid clipping of the giant aneurysm

During Surgery, with proximal and distal control, it was found that the tension in the aneurysm did not subside to allow safe clipping of aneurysm. Hence decision to proceed with total circulatory arrest was taken and the cardiac Surgeons pitched in to cool the temperature of the patient to 18⁰C (Deep hypothermia). At this temperature the heart of the patient stopped beating, achieving what is known as total circulatory arrest (TCA)wherein all blood flow to the brain is stopped. The Giant aneurysm became soft and the aneurysm was successfully clipped during TCA. Since the brain dies if blood flow is stopped for more than 5 mins, brain protection during TCA was achieved by deep hypothermia by cooling the patient’s body to 18⁰C which reduces brain metabolism and hence can tolerate cessation of blood flow for up to 1 hour. During this period the patient is clinically “dead” as EEG (brain activity) is flat, ECG (Heart activity) is flat. After the giant aneurysm is clipped, the body temperature is raised back to normal, the heart restarts spontaneously and the brain resumes its activity.

The video shows the patients cerebral angiogram before surgery, the patient scans before surgery including the huge giant aneurysm. The surgery video shows the dissection of the giant aneurysm & bleeding from the weak spot of the aneurysm during dissection. After achieving TCA, the giant aneurysm collapses like a deflated balloon allowing clipping of the “neck” of aneurysm with multiple clips. Then the patient is rewarmed, the heart restarts and the operation is completed.

Postoperative angiogram shows the elimination of the giant aneurysm and preservation of normal brain blood vessels. The patient is shown during follow-up and is independent and doing well.