Empowering early career vascular neurosurgeons in the endovascular Era: Managing intraoperative aneurysm rupture through a systematic algorithmic approach.

Intraoperative aneurysm rupture (IAR) is a feared complication and an unnerving experience for any neurosurgeon. If not managed properly, the consequences may be devastating. Although overall patient outcomes in IAR have been shown to improve with a neurosurgeon's experience, the likelihood of rupture does not necessarily decrease, and the key to success lies in appropriate management. Microsurgical dexterity, remaining calm and acting sensible are important skills that all neurosurgeons need to master early on in order to achieve good patient outcomes. The landscape of cerebrovascular disease management has evolved significantly, with a growing preference for endovascular approaches. Consequently, the case-load of microsurgical procedures available for trainees have been diminished. As microsurgical cases decline and the remaining cases become more complex, the need for a systematic approach to IAR management becomes critical, to ensure a swift and efficient response and to compensate for reduced experience. This video article aims to empower the next generation of neurosurgeons by emphasizing essential skills and a systematic algorithmic approach required to navigate IAR situations successfully. In this video, we present the unedited sequence of IAR management in a posterior communicating artery (PCoA) aneurysm, from rupture to clipping. A 43-year-old female patient presented with headache and diplopia caused by a left oculomotor nerve palsy. Computed tomography (CT) did not show subarachnoid hemorrhage, but CT angiogram revealed a 7-mm left PCoA aneurysm affecting the oculomotor nerve. Patient consent was obtained for surgical management. The predissection phase was uneventful, however during dissection of the aneurysm neck, IAR occurred from the aneurysm dome. One contributing factor to rupture may have been the traction exerted on the aneurysm with the dissector, possibly due to adhesion of the aneurysm dome to the tentorial edge. Additionally, performing intradural drilling of the anterior clinoid process during the approach could have provided better access to proximal control of the internal carotid artery, making clip application easier. By remaining calm and proceeding with the steps illustrated in the decision algorithm (Fig. 1), the right actions were made, and the aneurysm was successfully clipped. In this article, we provide early career vascular neurosurgeons with a systematic strategy for managing IAR, offering guidance that may facilitate the 'right move' during these high-stress situations.