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Anterior Temporal Artery Aneurysm: Minimal Pterional Craniotomy

October 28, 2019

Transcript

This is another video describing the techniques for clip ligation of anterior temporal artery aneurysm, and more specifically via the minimal Pterional Craniotomy technique. Here's the 49 year old male who presented with acute subarachnoid hemorrhage. CT angiogram demonstrated a right-sided small. As you can see here, anterior temporal artery aneurysm located here. You can see the origin of the anterior temporal artery from the neck of the aneurysm. The aneurysm is pointing in fairly. In this case, I attempted the linear incision and only used this part of the incision to do the craniotomy. I was prepared to extend the craniotomy if necessary but in this case only a linear incision, as you can see here was more than adequate. You can see the turn of the head. The incision dissection of temporalis muscle, the size of the craniotomy relatively small. Temporal lobe, frontal lobe, wide dissection of the fisher using the inside to outside technique until the aneurysm is encountered. Obviously one has to be very careful to preserve the origin of anterior temporal artery. Which is located there as you saw a moment ago. Temporary clip was placed on M one. Here you can see the origin of the anterior temporal artery. A moment ago here, you can see the circumferential dissection around the neck of the aneurysm. I placed the tentative clip initially to decompress the aneurysm, while trying to preserve the origin of the anterior temporal artery. I did not place the clip all the way across because I wanted to preserve the origin of the anterior temporal artery. I'll go ahead and now dissect around the dome of aneurism. After the temporary clip is placed, and also the tentative clip was applied. Here going around the entire aneurysm. This strategy is important to make sure the aneurysm is completely excluded. I may actually slightly coagulate the dome, to gather the dome and be able to see around the neck of the aneurysm. Very adequately. Here you can see some of the perforators behind the aneurysm. There was some venous bleeding that was controlled via a piece of cotton. Here again looking around the aneurysm. I'll go ahead and place another clip. This still to the initial clip, but now all the way across the neck and this pterional clipping technique will preserve the origin of the anterior temporal artery. And at the same time, occlude the neck as close to the M one as possible. So one clip's slightly shorter. One clip is all the way across. This way the origin of anterior temporal artery is very nicely preserved. Again, inspecting all the way around. You can see anterior temporal artery, you can see the aneurysm dome occluded all the way across. Using micro-Doppler ultrasound, to make sure that all the vessels are patent. Here's the fluorescein angiography demonstrating that the aneurysm is completely occluded and the origin of the anterior temporal artery is patent and unaffected by the clip lights. A nice view of the anterior temporal artery at the depth of our dissection. Preparing soak therefore maybe used to relieve any vasospasm in the vasculature here, you can see the final product. Minimal amount of injury to their frontal temporal operculum via this minimalistic exposure. Here's another view for orientation and post operative CT angiogram demonstrated complete exclusion of aneurysm without any complicating features. And this patient made an excellent recovery. This video nicely demonstrates the technique of a minimal pterional approach for clip ligation of MCN aneurysms and the importance of tentative clip to deflate the aneurysm so I can work more effectively around the neck and dome of the aneurysm while minimizing the temporary clip time on the M one branch and potentially decrease the risk of disco ischemia. And then the tentative clipping technique, the more proximal clip shorter than a distal one can also be effective. For preservation of the origin of some of the arteries that start from the neck of the aneurysm and a little bit more distal along the region. Thank you.

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