Branch-Critical Clipping of a Ruptured Carotid–Posterior Communicating Aneurysm with Fetal PCA Configuration

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Author,

• The article needs substantial revisions to text and reference correction needed as the manuscript in its current form is significantly too long for a standard Case Report.
• The writing style is overly verbose, repetitive, and flowery, which dilutes the scientific message. For example:

• Shorten the introduction to focus on aSAH pathophysiology and on the specific challenge of PCom aneurysms with fPCA variants.
• In case presentation the patient's initial presentation and ICU course is excessively detailed (e.g., describing the "thunderclap type of headache," detailed descriptions of specific cognitive tests). Please summarize the pre-operative status and post-operative course more concisely.
• Discussion: This section is too long and inflated as it repeats the case details too often, please focus on the specific surgical nuance of the fPCA anatomy.
• Table 1 is not required and can be removed.
• There appears to be a mismatch between the text and the cited references. Some references seem completely irrelevant to the subject matter.
• Reference 18 (Franchi et al., 2025):  This is about plastic surgery/flaps, not neurosurgery.
• Reference 20 (Rastogi et al., 2022):  This is irrelevant to intracranial aneurysm clipping.
• Reference 23 (Jankowska-Kulawy, 2022):  This is a basic science paper irrelevant to clinical bedside metrics.
• Please use standard, concise medical terminology for example "orderly resolution of the global SAH phenotype").

Comments on the Quality of English Language

Needs improvement

Author Response

Dear Esteemed Academic Reviewer,

We thank you for your careful reading of our manuscript and for the clear, constructive, and highly practical recommendations. We are grateful for your emphasis on conciseness, precision of terminology, and reference accuracy. Your comments helped us refine the manuscript into a more standard and focused Case Report, with a clearer scientific message centered on the branch-critical fetal-type posterior cerebral artery anatomy and its implications for microsurgical reconstruction.

Below, we respond to each point in detail and describe the specific revisions implemented.

1) Overall length and need for substantial revisions

Reviewer comment: The manuscript is significantly too long for a standard Case Report and needs substantial revision, including text and reference correction.

Response: We fully agree and appreciate this important observation. We performed a comprehensive restructuring and condensation of the manuscript to meet standard Case Report expectations. Redundant explanatory passages were removed or merged, and multiple sections were rewritten to increase information density while preserving clinical and operative detail. In parallel, we carefully reviewed and corrected the reference list to ensure that all citations are relevant and directly support the associated statements.

2) Writing style overly verbose, repetitive, and “flowery”

Reviewer comment: The writing style is overly verbose, repetitive, and flowery, diluting the scientific message.

Response: We are grateful for this guidance and agree that the original version contained unnecessary narrative expansion. We revised the language throughout to adopt a more direct, standard clinical and microsurgical tone. We removed rhetorical phrasing, reduced interpretive restatements, shortened sentence structures, and replaced non-standard expressions with concise medical terminology.

 

3) Introduction should be shorter and focused on aSAH pathophysiology and the challenge of PCom aneurysms with fPCA

Reviewer comment: Shorten the introduction to focus on aSAH pathophysiology and on the specific challenge of PCom aneurysms with fPCA variants.

Response: The Introduction has been rewritten and substantially shortened. It now focuses on (i) the two-phase injury concept in aSAH (initial hemorrhagic insult followed by secondary vulnerability), and (ii) the specific technical challenge of carotid–PCom aneurysms with fPCA configuration, where the branch ostium may overlap the aneurysm neck plane, requiring junction-preserving reconstruction.

4) Case Presentation is overly detailed; summarize pre-operative status and ICU course more concisely

Reviewer comment: The initial presentation and ICU course are excessively detailed (e.g., “thunderclap type headache,” detailed cognitive testing). Please summarize more concisely.

Response: We agree and thank you for highlighting this. The Case Presentation has been rewritten into a more compact, case-report-appropriate format. We retained essential objective severity grading and physiological parameters (GCS, FOUR, HH/WFNS, Fisher grade, BP/CO₂ targets, TCD velocities, nimodipine dosing, imaging timelines), but removed narrative expansions and reduced repeated physiologic explanations. The ICU course is now presented using standard language and objective milestones rather than detailed descriptive commentary.

5) Discussion too long and repeats case details; focus on surgical nuance of fPCA anatomy

Reviewer comment: Discussion is too long and inflated, repeating case details; focus on specific fPCA surgical nuance.

Response: The Discussion was comprehensively rewritten to avoid retelling the case. It now focuses on the core teaching point: the fetal-type PCA configuration transforms aneurysm exclusion into a junction-preserving reconstruction problem with minimal tolerance for clip-induced stenosis. We retained the mechanistic framing of secondary injury only insofar as it directly supports the clinical relevance of branch patency during the DCI-risk window, and we removed repeated reiteration of the clinical course.

6) Table 1 is not required and can be removed

Reviewer comment: Table 1 is not required and can be removed.

Response: We appreciate this important suggestion and fully understand the concern that tables in case reports can unintentionally expand the scope toward a review format. After careful revision, we elected to retain Table 1 because it serves a narrowly defined, case-anchored purpose: it provides a compact, single-page framework that links the patient’s high-grade hemorrhage phenotype and branch-critical anatomy to the specific postoperative vulnerability window (DCI/CSF dynamics) that guided our structured monitoring and management strategy.

 

7) Mismatch between text and cited references; several references appear irrelevant

Reviewer comment: Some citations are mismatched or irrelevant, including:

Ref 18 (Franchi et al., 2025): plastic surgery/flaps

Ref 20 (Rastogi et al., 2022): irrelevant to aneurysm clipping

Ref 23 (Jankowska-Kulawy, 2022): basic science paper irrelevant to clinical bedside metrics

Response: We are grateful for your careful attention to this critical issue and fully agree that these citations were inappropriate in the original submission. We performed a systematic citation audit, removed the irrelevant references, and revised the surrounding text so that each remaining citation directly supports the statement being made. Where necessary, we replaced these citations with literature appropriate to intracranial aneurysm management, DCI risk, and neurocritical care monitoring, or removed the citation-dependent statement if it was not essential.

8) Use standard, concise medical terminology; avoid phrases like “orderly resolution of the global SAH phenotype”

Reviewer comment: Please use standard, concise medical terminology and avoid non-standard phrasing.

Response: We completely agree and sincerely appreciate this point. We removed non-standard expressions and replaced them with conventional clinical language throughout the manuscript. For example, instead of “orderly resolution of the global SAH phenotype,” we now describe objective clinical improvement in terms of resolution of meningismus, stabilization of neurological examinations, cognitive recovery on validated metrics, and absence of delayed ischemic changes on imaging.

 

 

We are very grateful for your thoughtful critique, which significantly improved the clarity, focus, and scientific rigor of this report. Your guidance helped us align the manuscript with the expectations of a concise, high-quality Case Report while preserving the key anatomical and microsurgical teaching point regarding fetal PCA-associated branch-critical clipping.

With appreciation and respect!!!

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

thank you for your work.

Please explain:

1. sentence in the introduction part - ...even if the aneurysm responsible for the rupture of an aneurysm...(gramatically not clear)
2. please put a reference for the statement that  PCom aneurysm represent one quarter of all intracranial aneurysms
3. "acute meningeal haemorrhagic event" - please explain this term or change to more commonly used. Also, NIHSS score is not commonly used for SAH, so it would be advised to avoid it
4. Extensive explanation of differential diagnosis in the case report part is not advisable - it would be more appropriate to do it in discussion part, if necessary at all.... as the clinical picture was not so atypical at all. Also I would highly recommend to shorten the discussion in the whole case report part 
5. there is no information about initial CT scan - which is still  a first step in the diagnostic work-up - please explain - it is mentioned after, but it is not clear how was the diagnostic work-up performed
6. I would suggest to redesign the article in a way that a case report part stays "case report" and all diagnostic, pathophysiologic and treatment dilemmas are discussed in the discussion part - not combined with the course of illness.

Author Response

Dear Esteemed Academic Reviewer,

We thank you for your careful evaluation of our manuscript and for the thoughtful, highly practical guidance you provided. We are grateful for your attention to scientific clarity, appropriate terminology, and case report structure. Your comments helped us further refine the manuscript to ensure that the “Case Presentation” remains strictly factual and chronological, while diagnostic reasoning and pathophysiologic interpretation are reserved for the Discussion, consistent with standard Case Report expectations.

Below, we provide a point-by-point response and outline the specific revisions implemented.

 

1) Introduction: grammatical clarification

Reviewer comment: The sentence “…even if the aneurysm responsible for the rupture of an aneurysm…” is grammatically unclear.

Response: We appreciate you highlighting this phrasing issue. We fully agree that the sentence was redundant and unclear. We revised it to a grammatically correct and concise formulation that preserves the intended meaning.

 

 

 

2) Provide a reference for “PCom aneurysms represent one quarter of all intracranial aneurysms”

Reviewer comment: Please provide a reference for the statement that PCom aneurysms account for about one quarter of all intracranial aneurysms.

Response: Thank you for this important observation.

 

3) “Acute meningeal hemorrhagic event” terminology and NIHSS usage

Reviewer comment: “Acute meningeal haemorrhagic event” is not a commonly used term and should be clarified or replaced. NIHSS is not commonly used in SAH and should be avoided.

Response: We replaced “acute meningeal hemorrhagic event” with standard terminology (e.g., “acute aneurysmal subarachnoid hemorrhage” / “acute subarachnoid hemorrhage with meningismus”), which is clearer and more universally accepted.

 

4) Differential diagnosis description is overly extensive for a case report

Reviewer comment: Extensive differential diagnosis explanation is not advisable within the Case Presentation; it would be more appropriate in the Discussion if needed. The clinical picture was not atypical, and the case report section should be shortened overall.

Response: We appreciate this important structural recommendation and fully agree. We significantly shortened the differential diagnosis narrative and removed interpretive expansions from the Case Presentation. The clinical presentation is now described as a straightforward SAH presentation supported by objective findings, and only essential diagnostic reasoning is retained where it directly explains the diagnostic workflow.

 

5) Clarify the diagnostic workflow: initial CT scan

Reviewer comment: There is no clear information about the initial CT scan as the first step of diagnostic work-up; it is mentioned later, but the workflow is not clear.

Response: Thank you for pointing this out.

 

6) Structural recommendation: keep “Case Presentation” factual; move dilemmas/interpretation to Discussion

Reviewer comment: Redesign the article so that the case report section remains a “case report,” while diagnostic, pathophysiologic, and treatment dilemmas are addressed in the Discussion rather than combined with the illness course.

Response: We are grateful for this overarching structural guidance and fully agree. We revised the manuscript accordingly. The Case Presentation is now written as a concise, factual, and chronological account of presentation, diagnostic work-up, operative strategy, postoperative monitoring, and follow-up outcome. The Discussion has been restructured to contain the interpretive content, including the key teaching point of fetal PCA-associated neck-plane overlap requiring junction-preserving reconstruction and the rationale for structured postoperative surveillance in the DCI-risk window.

 

 

 

We thank you again for your detailed and collegial critique. Your recommendations meaningfully improved the manuscript’s clarity, clinical precision, and adherence to case report conventions. We believe the revised version now communicates the key surgical nuance more effectively while remaining appropriately concise and methodologically transparent.

With appreciation and profound respect!!!

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Authors have made suggested changes.

Comments on the Quality of English Language

Needs improvement

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

thank you for this careful and thorough review, and I can congratulate you for this case report as well as discussion.