Atherosclerotic MCA aneurysms can be quite problematic at times, let's review some of the nuance of technique for a complication avoidance. This is a 61 year old female who presented with a right sided, higher grade ICA stenosis and associated MCA aneurysm. You can see the isolated MCA territory leading to the aneurism itself. There was no evidence of calcification on the CT angiogram. She subsequently underwent a right-sided frontotemporal craniotomy. Sylvian Fissure was opened. In the inside to outside technique. Again, you can see the traditional microsurgical techniques for opening the superficial thick arachnoid mans. The spreading action of the bipolar forceps are utilized to continue the deeper planes of dissection. Piece of cotton was used to keep the fissure patent during the distill dissection. The M2 branches were found and followed to the level of the MCA bifurcation and the aneurysm. Further opening of the Fisher was deemed necessary. The opening of the arachnoid bands would allow better identification of the vascular anatomy. Here's a portion of the aneurism that appears very atherosclerotic. Here's the M1, more proximally along the fissure. It appears also partially atherosclerotic, small portion of the brain layered over the dome had to be removed so that the temporal branch or trunk can be clearly defined. And the neck of the aneurysm be isolated. Here you can see the dome of the aneurysm, it's being dissected away from the surrounding brain. I continue dissection until the neck is better visualizeable, here you can see the frontal trunk. The neck of the aneurysm. Circumferential dissection of the neck continues. Temporary clip was placed across the M1 for a short period, so that aneurysm can be deflated and the neck better defined. Due to evidence of atherosclerosis at the level of the neck I did not wanna compromise the atrium or the bifurcation of the MCA and therefore small amount of neck was left behind. Here you can see some residual atherosclerotic neck to keep the patency of the M2 trunks intact. This dark ear was subsequently also clipped. All the M2 branches appeared patent. No evidence of significant stenosis was apparent at least on intraoperative ICG. Unfortunately, this patient suffered from a partial anterior cortical stroke, most likely related to one of the distal M1 perforating vessels or lateral inter coastal arteries. I suspected that the presence of atherosclerosis led to occurrence of this ischemia. And therefore the atherosclerotic aneurysms have to be really carefully managed in all the perforating vessels adequately protected during clip ligation and temporary occlusion times should be kept to a minimum, especially in a patient with high grade ISA stenosis in an isolated MCA territory, so that such ischemia can be avoided, thank you.
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