Posterior communicating (PComm) artery aneurysm technique

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  1. Posterior communicating artery gives rise to 4-12 branches that supply the genu and anterior third of the posterior limb of the internal capsule, the anterior third of the thalamus, and the walls of the third ventricle; also gives off branches to the optic tract, optic chiasm, cerebral peduncle, and tuber cinereum
  2. 86% of Pcomm aneurysms project posterolaterally and involve the oculomotor nerve in 1/3 of cases
  3. operative technique
    1. place patient in Mayfield and rotate patient about 30 degrees away from vertical
    2. skin incision: from 1 cm in front of tragus curving slightly anteriorly staying behind hairline to widow’s peak, incise skin down to but not through temporalis fascia
    3. burr holes: one at posterior insertion of the zygomatic arch with a second burr hole made at the intersection of the zygomatic bone, the superior temporal line and the suprorbital ridge with the hole as low as possible on the orbit
    4. craniotomy is carried forward 2-3 cm from the front hole and then backward in a semicircle to the posterior burr hold and then forward until the drill hangs up over the sphenoid wing
    5. dural flap: curvilinear retracted inferiorly
    6. dissect down the Sylvian fissure, retract frontal lobe and come down on optic nerve, retract temporal tip, incise the arachnoid from anterior to posterior over the optic nerve to release CSF and then dissect carotid to give access to the proximal ICA for proximal control purposes
    7. be careful to preserve anterior choroidal
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