These aneurysms can be treated by the performance of a high-flow bypass graft (radial artery or saphenous vein) from the external carotid artery or the internal maxillary artery to the M2 divisions of the middle cerebral artery, with simultaneous proximal occlusion or trapping of the giant aneurysm. subarachnoid), and this region is home to many kinds of complex aneurysms. The first classification was devised by Fischer in 1938, designating intracranial ICA from C1-C5, against direction of blood flow. Our own NYU classification of ICA segments, developed as a result of angiograhic and cross-sectional review and discussion, is based predominantly on endovascular considerations. The ACA pursues an infraoptic course (below the optic nerve), as does the rarely seen ventral ophthalmic artery — in fact this variant is a perfect demonstration of the infraoptic “A1” segment ACA in fact representing the ventral ophthalmic artery portion extending from the ACOM complex to the ophthalmic segment . The one in most widespread use —, Absolutely magnificent dissections of this area (among others) can be found in the spectacular works of Rhoton, which are (or should be) familiar to any neurosurgical pracititioner or trainee. This variant comes up with unfortunate regularity as a middle ear “pulsatile mass”, subjected to an unwitting biopsy. In the cavenous sinus, the artery is surrounded by venous plexus, such that carotid rupture there leads to a carotid-cavernous fistula. They are surgically important, particularly when it comes to procedures related to the posterior nasopharyngeal and oropharyngeal walls. Many others — if you are a surgeon, you know. When seeing a medially-projecting cavernous aneurysm, CT is mandatory. The aberrant carotid is made up of the ascending pharyngeal artery, its inferior tympanic branch, and the caroticotympanic branch of the ICA. They settle in an area of great hemodynamic stress. Second, regional anatomy, and dural rings in particular, are modified by disease (aneurysms), which remodel, distort and destroy adjacent tissue (dehiscence), such that, short of surgical dissection and microscope observation, the integrity of dural ring can never be fully determined in setting of adjacent pathology. ICA aneurysms are not a uniform group of lesions and require a thoughtful and individualized approach. 3D-DSA view (left), from medial to lateral, of the same aneurysm, underscoring its typical lateral growth pattern. Various measurements have been made as part of Pipeline embolization planning; center DSA frontal oblique projection image with additional careful measurements; image on right demonstrates a Pipeline construct of multiple overlapping devices. This modified the conceptual framework, emphasizing aneurysm dome morphology and neck anatomy, with less critical attention to surgical landmarks. The 3D-DSA image is particularly instructive for those who look to underlying ICA dysplasia as a necessary pre-condition for aneurysm growth. All of these have been sub-classified in various neurosurgical works, as morphology, origin, and projection of the aneurysm significantly affected surgical approach and associated issues/risks. We agree that a separate lacerum segment does not seem to be necessary, both anatomically and pathophysiologically, as aneurysms of the petrous segment almost always extend into the Lacerum portion of the ICA, but very rarely beyond the PLL. 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