Atherosclerotic MCA Aneurysm: MCA Tear

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This video is a good presentation of the challenges we face in handling atherosclerotic aneurysms, and also describes some of the ways we can handle misadventures during the operation. This is a 46 year-old female who presented with an incidental nine millimeter left-sided MCA aneurysm. The CT angiogram demonstrates the morphology of the aneurysm and incorporation of the M two origins into the neck of the aneurysm. There is no obvious evidence of significant atherosclerosis or calcification following a left frontotemporal craniotomy and wide opening of the Sylvian fissure, the M one was identified. You can see the atherosclerosis at the neck of the aneurysm and the origin of the M two here. This segment of the M two was very adhering to the dome. Aneurysm Rafi using bipolar coagulation was used. Here you can see, again, the aneurysm, the part of the trunk that was very adherent to the dome of the aneurysm. I felt that aggressive dissection in this area can place both the lumen of the vessel and the dome of the aneurysm at risk. Therefore an angle finisher clip was used to exclude the neck of the aneurysm while leaving the atherosclerosis at the neck alone. I did not feel aggressive exclusion of the atherosclerosis is necessary as this maneuver can place the inlets of the M two trunks at the risk of compromise and lead to distal ischemia. I tried a few different clip configurations, again, trying to preserve that trunk's origin, a second clip would be necessary to close the other end of the aneurysm neck. Unfortunately, when I was removing and replacing the other clip an injury to one of the M two trunks occurred, we're going to review that in a moment. You can see here, it's very unfortunate. Primary closure of the bleeding point can be problematic and may compound the bleeding. I use a piece of cotton soaked in thrombin to wrap the area of the bleeding, some patience and gentle tamponade are quite effective. You can see the area of the bleeding is sealed, intraoperative ICG demonstrated some further filling of the aneurysm and these clips had to be repositioned. Here you can see some of the filling here, additional replacement of the clips was necessary. Here's the final construct. I was relatively satisfied. Here you can see final exclusion of the aneurysm Pepperfry soaked cotton was also used to relieve the spasm within the trunk. Here's the, again the final result. Postoperative angiogram revealed satisfactory exclusion of the aneurysm and the CT scan did not reveal any evidence of ischemia. And this patient recovered from her surgery very well. Again, misadventures are not necessarily disastrous if there are properly handled. In this case, you can see that bleeding point from the MC was adequately addressed and it's undesirable sequella were avoided, thank you.

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