December 02, 2015
Hello. My name is Aaron Cohen. This video reviews taken coronary analysis for clip ligation of MCA aneurysms. As well as two different fluorescent techniques for evaluation of vascular flow and exclusion of the aneurysms. I'm going to use the case of one of my patients, a 42 year old female, who presented with an incidental atherosclerotic, 10 mm right-sided MCA aneurysm. You can see the aneurysm with it's very broad base. Making it more amenable for definitive treatment through microsurgical techniques. The patient underwent a right frontotemporal craniotomy. Under operative microscope guidance, the Sylvius Fissure is widely open all the way anteriorly. This is the anterior temporal artery. The Sphenoid Wing is located here. You can more the magnified view of the vessels. If when we looked anteriorly along the aneurysm we were unable to find the M1. Therefore, I looked posterior to the aneurysm and you can see the M1 available there and exposed for proximal control. I went ahead and further dissected anteriorly to mobilize the frontal lobe away from the temporal lobe, with a wide opening of the arachnoid membranes. Along the interior limb of the Sylvian fissure. This allows prevention of the use of rigid retractors and use of dynamic retraction to continue microsurgery within the Sylvian fissure. Here's a temporary clip placed on the M1. Here's M1 Here. Now the aneurysm has been deflated and its dome is being mobilized from the frontal lobe. I placed the first curve clip and another clip from the temporal side, hoping these clips would work. You can see on the fluorescence angiography that the energy is not filling at this time. However, the frontal branch or the frontal truck of the MC is not filling as well. The temporal trunk is filling readily and all the feeders are patent. I went ahead and replaced this curve clip, slightly away from the MC bifurcation And with the replacement of the clip, you can see that on ICG, both branches are filling and another two clips or a third clip were placed to completely exclude the aneurysm without any chance for further slippage of the first two clips. You can see on the post-operative 3D angiogram. The aneurysm is completely excluded. Thank you for your attention.
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