Bilobed MCA Aneurysm

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This video describes the techniques for clip ligation of MCA aneurysms, and more specifically the strategies for bilobed aneurysms. This is a 63 year-old female with an unruptured MCA aneurysm. CT angiography demonstrated the location of the aneurysm. An angiogram was also performed, reveals the aneurysm. However, the exact morphology of the aneurysm was difficult to see on this view of the aneurysm. Here's the 3D reconstruction view of the aneurysm from the CTA. We went ahead and completed a left-sided front temporal craniotomy, frontal lobe, temporal lobe, Sylvian fissure, relatively easy fissure to dissect using the inside to outside technique. Here you can see the aneurysm being mobilized. Obviously very careful dissection, a thorough inspection around the aneurism is critical to make sure that the morphology of the aneurism is adequately understood. So as I continue to dissect, you can see the M1 temporary vascular control was secured. And I went ahead to dissect around the superior pole of the aneurism, and you can see the very bi-lobed shape of this aneurysm that was not easily recognized on preoperative imaging in the superior lobe, inferior lobe underneath the temporal lobe. So one has to, again, circumferentially dissect around the aneurysm to make sure that the neck of the aneurysm and the morphology of the dome is very well understood. Also, now the perforators are included within the clip plates. So here you can see the two lobes, very unusually shaped aneurysm. They'll have other bifurcation, the upper and lower lobe of aneurism. Here's the area of the bifurcation to temporary clip allows deflation of the domes and manipulation of the domes without significant risk of hemorrhage. I'll make sure that I mobilize both domes. And then next use a curve clip, gather both domes within the clip and clip both aneurysms using a single clip. I think any other clipping strategy can be quite complex and not necessarily beneficial. Again, temporary clip deflation of aneurysms allows easy manipulation of the necks and the domes and inclusion of aneurysm necks within the clip plates. Micro-Doppler ultrasonography revealed patency of their branching vessels. So you can see the aneurysm it's nicely clipped, no complicating features noted intraoperatively. ICG angiography reveals occlusion of the aneurysm and patency of all the branching vessels. The magnified view of the operative field. Here's the postoperative angiogram revealing complete exclusion of the aneurysms, no evidence of ischemia on the CT scan, and this patient made an excellent recovery. This video emphasizes the importance of careful dissection so that the morphology of the aneurysm is very well understood as preoperative imaging, including angiography can at times not reveal the complete details of the aneurysm neck and dome. Use of temporary clip and deflation of the aneurysm domes, allows very easy manipulation of the domes and clear definitive inclusion of aneurysms within the clip plates. Thank you.

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