Craniotomy and ACom Aneurysm Clipping

Clipping of a Previously-Coiled AComA Aneurysm

This illustration was created as part of our Surgical Illustration I course, which involved viewing an open procedure of our choosing, describing it through a series of sketches, and selecting one or more sketches to render.

I viewed and sketched a pterional craniotomy with an anterior communicating artery aneurysm clipping (a 9-hour procedure) performed by Dr. Rafael Tamargo. I consulted with Dr. Tamargo and my faculty advisor, Lydia Gregg, about my sketches, refined them, and chose to render the clipping.

View the full series, as well as selected pages from a mock journal layout, below.

2025

Johns Hopkins School of Medicine

Lydia Gregg, Dr. Rafael Tamargo

Adobe Photoshop, Procreate

Presentation Recording

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1: Scalp incisions a) to temporalis fascia and b) to bone

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2) Z-shaped incision made in temporalis muscle with electrocautery, leaving a cuff behind

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3: Four burr holes created as shown, with a fifth hole created over the pterional region. Cranium opened along dotted line

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4: Drill and rongeur used to eat sphenoid bone away from sylvian fissure

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5: Dura mater opened in a semicircle

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6: Dissection in the sylvian fissure. Camera represents microscope angle

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7: Sylvian fissure dissected to CNI, with frontal lobe retracted. Adhesions are present

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8: Sylvian fissure dissected to CNII and the Internal Carotid Artery bifurcation

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9: Gyrus rectus cauterized to reveal aneurysm

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10: A1 segments of Anterior Cerebral Artery temporarily clipped; right A1 is diminuitive

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11: Permanent clip applied to base of aneurysm

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12: Temporary clips removed, restoring bloodflow to the ACA

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13: Dura closed with simple interrupted sutures

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14: Cranium replaced, with snowflake-shaped interlink plates over burr holes and mesh over pterional region

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15: Temporalis muscle replaced and sutured to mesh plate and muscle cuff, shifting the bulk of the muscle anteriorly to combat atrophy

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16: Scalp closed with a layer of inverted sutures and a layer of running sutures, with a drain placed