This is another video in this series of videos, reviewing technical nuances for clip ligation of atherosclerotic MC aneurysms. This is a 65-year-old female who presented with acute onset subarachnoid hemorrhage and was diagnosed with a right-sided MCA bifurcation aneurysm on a CT angiogram. You can see the pattern of blood on the angiogram and more over the right sylvian fissure. A right-sided frontotemporal craniotomy was completed. Sylvian fissure was widely exposed. The M2 branches were followed to the level of the bifurcation. You can see the dense clot within the fissure. Here's the M2 trunk to the temporal lobe. Here's the aneurysm, based more toward the frontal M2 trunk, located here. The M2 trunk of the frontal lobe is adherent to the lateral neck of the aneurysm. A temporary clip was placed, encompassing the bifurcation and the proximal portion of the frontal M2. You can see now, maneuvers for mobilizing the frontal M2 away from the neck of the aneurysm, so that appropriate clip application is possible. The frontal M2 is quite adherent. Sharp dissection is the best methodology for releasing the aneurysm neck. I'm working across the neck of the aneurysm in this situation. The aneurysm is quite atherosclerotic across and around the circumference of its neck. Here's the bifurcation. The M2 is being further dissected away from the neck. Here's another view of the aneurysm neck from its anterior circumference. I continue to develop the plane between the aneurysm neck and the proximal M2. Due to presence of significant atherosclerosis within neck of the aneurysm, I was planning on using two curved clips coming from both the frontal and temporal sides to completely collapse the aneurysm neck. I'm now getting close to the axilla of the frontal M2. The circumference of the aneurysm neck is now more identifiable. A short curve clip was placed first from the frontal side. Here you can see the final deployment of this clip. And another clip was placed from the temporal side so that the aneurysm can be reliably excluded. The second clip is just above, and more distal, to the first clip. Making sure that the temporal neck of the aneurysm is completely excluded. The atrium of the bifurcation is patent. The result of the ICG angiogram demonstrates complete exclusion in the aneurysm and patency of the bifurcation and both M2 trunks. The aneurysm was penetrated, since it was so atherosclerotic, to assure that no false negative result in the ICG was possible. Postoperative angiogram ultimately demonstrated complete exclusion of the aneurysm sac without any compromise of the surrounding branching vessels. Thank you.
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