Bulbous MCA Aneurysm: Aneurysmorrhaphy
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This is another nice example of aneurysmorrhaphy for assisting with clip ligation of bulbous MCA aneurysms. This is a 50 year old female who presented with an incidental left sided seven millimeter MCA aneurism. You can see the classic morphology and projection of this MCA aneurysm located on the left side. Patient subsequently underwent a left front temporal craniotomy. The sylvian fissure was widely dissected. The MCA branches were carefully exposed. You can see the M1 deep within the fissure. Here's the aneurysm with evidence of atherosclerosis around the nick of the aneurism. Aneurism appears somewhat bulbous. An adherent perforating branch. Here is the frontal M2 trunk. The temporal M2 branch is not evident, it's most likely hiding behind the aneurysm sac. A temporary clip on M1 was placed so that the aneurysm can be deflated. And the M2 trunk can be found just hiding underneath the aneurysm sac. Here is the M2 trunk. You can see the bulbous portion of the aneurism interfering with adequate visualization around the aneurysm sac and placement of the clip. I used bipolar coagulation to reduce the sac under temporary occlusion of M1. You can see irrigation is used, only the midsection of the aneurysm is coagulated. The nick is left alone. Here is further reduction in the aneurysm dome so that the nick can be more well defined and visible for definitive clip placement. Here's the M2 trunk, temporal one. It's more visible after reduction of the sac. Here's the dome of the aneurism further coagulated and reduced. Dissected from the surrounding pial surfaces. Here you can see the origin of the temporal M2 is now much more visible after the sac has been reduced. Now a curve clip can be placed across the nick of aneurism with clear visualization of the M2 and preservation of the origin of the M2, as it curves around the nick of the aneurysm more inferioraly. Intraoperative fluorescein angiogram demonstrates complete exclusion of the aneurysm with patency of the surrounding branching vessels. The final condition of the brain is demonstrated. And post operative angiogram confirms complete exclusion of the aneurism without any residual aneurysm nick. In addition the CT scan confirms lack of evidence of ischemia, and this patient recovered from her surgery uneventfully. Thank you.
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