Challenges in Splitting the Fissure during MCA Aneurysm Clipping Free

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This is another video discussing technical challenges in splitting the Fissure that's filled with blood as related to an MCA aneurysm. Obviously the blood makes the oprachilar more adherent and makes the dissection very difficult. As the oprachilar can become much more challenging to find and the arachnoid membranes are obscured. This is a patient who presented with spontaneous Subarachnoid hemorrhage. CT scan demonstrated a medium amount of blood in the left Sylvian fissure. Let's go ahead and redo the CT angiography. In this case, a left sided MCA aneurysm was diagnosed right at the level of the bifurcation. The operative findings are as follows a round Knife was used to open the superficial Fissure. One has to be careful to protect the veins as they can be difficult to see due to the presence of the thick clot. The gentle spring action of the bipolar is used to find the arachnoid membranes. Here you can see the inside to outside technique where the Fissure is open deep initially, and then one can move from deep to superficial. And again, always have the vessels in mind to go through the Fissure and avoid getting into the peel Membranes. Irrigation can specially help with evacuating the blood as well. You can see the dynamic retraction of the shaft of the suction parallel to the peel membrane. Here I'm looking for the vessels, staying outside the peal membranes, remove the block clot. As you can see, the clot can be quite tenacious, especially with patients who have had multiple hemorrhages before going to the emergency room. Here you can see one of the distal MCA branches that I'm going follow more proximately until the M2 branches are found. Sharp dissection, especially helpful. Again, staying on the M2 branches and moving toward the bifurcation. This is the temporal branch obviously. The entry fissure is also wildly dissected. So the frontal and temporal oprachilar can be easily mobilized without significant retraction on the oprachilar. In due to some intercranial tension related to the hemorrhage and irritation of the cortex. The brain can be quite resistant to a mobilization and why the arachnoid dissection is really important to avoid significant force on the oprachilar. Here's the arachnoid opening or this fenoidal segment of the fissure. You can see the wide dissection of the Fissure is very important for the ability of the surgeon to see all the vessels and understand the anatomy here's the neck of aneurysm that is exposed here is M1. Here's the M2 branches. There has to be another M2 branch. Let's go ahead and put a temporary clip under for suppression and dissect the neck a little bit more effectively. I expect to find the branching vessel, the frontal branch, just behind the aneurysm. In this case it wasn't easily possible to see it without putting a tentative clip first, and then having a chance to dissect the dome completely, to be able to inspect the aneurism circumferentially thoroughly, to again understand the morphology and congregation of the origin of the frontal branch. Here. You can see the frontal branch that is evident. Here's the aneurism. So the entire dome of aneurysm has to be mobilized for me to be able to see the origin of the frontal trunk Using sharp dissection, here's the aneurysm, here's the dome of the aneurysm I'm mobilizing the dome, following the route of their frontal trunk to its origin. Here, you can see the aneurism completely moved out of the it's original location. Here's the origin of the frontal branch actually being stenosed in a completely occluded by the tentative clip. So I'm going to apply the temporary clip again and obviously move my clip. But before I do that, the aneurysm is relatively bulbous, I'll go ahead and use the bipolar coagulation aneurysmorrhaphy to shrink the aneurysm. This technique can really help nicely to shrink the aneurysm and allow clip application to completely exclude the neck and allow the surgeon to see around the dome of the aneurysm. Here, you can see the entire aneurysm dissected one really has to understand the anatomy very well. Otherwise clip ligation more blindly can lead to residual aneurysm or inadvertent occlusion or stenosing of the branching vessels. Here's further shrinking of the dome Now it's easily manipulatable, and one can place a short clip across the neck, as it can really see around the dome very well and nice complete exclusion of the aneurysm neck is possible just all the way to the inlets of the frontal end temporal branches Here is a intraoperative ICG angiography reveals complete exclusion with the aneurysm, the clip and patency of the temporal and frontal branches. Very happy with the result. Here's the final product. You can see relatively a traumatic dissection of the Fissure. Postop angiography revealed complete exclusion of the aneurysm, in this case here is the clip here's the frontal branch complete exclusion of the aneurysm without any complicating features. And this patient did not have any complications from the clipping. You can see an MRI scan that was obtained for an unrelated reason after surgery revealed a traumatic dissection of the fissure without any evidence of injury to their oprachilar. So I think a traumatic opening of the Fissure, even in the presence of moderate amount of blood is possible. As long as careful techniques are used, vessels are utilized as a roadmap and the pure membranes are carefully protected. Thank you.

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