Let's review clipping strategies for multilobulated complex MCA aneurysms. This is a 31 year old female who presented with a relatively complex MCA aneurysm. The complexity of the aneurysm was not apparent on the CT angiogram. There was only an evidence of a bulbous mass at the level of the left MCA bifurcation relating to more dense blood at the same area on the CT. She subsequently underwent a left front temporal craniotomy. You can see the dense amount of blood related to the aneurysm rupture. The MCA was quite adherent. She's young and lots of blood within her fissure making the dissection process quite challenging. I continue to persist dissect the fissure, follow the routes of M2s toward the MCA bifurcation. Here you can see these M2 trunks that are being pursued toward the M1 I avoided the area of innerism so that proximal control can be secured before the neck is manipulated. Here's the M1 within the deeper aspects of the fissure. Now that proximal control is available. I attempted some dissection of the aneurysm before a temporary clip is placed over the M1. Now a temporary clip is placed under burst suppression. The plates are secured around the entire caliber of the M1. You can see there is a lobe of aneurysm, actually adherent to the frontal lobe. Here's one of the M2 trunks. Here's another M2 trunk. Therefore this is most likely a trifurcation and one has to clearly define the anatomy before the any permanent clip is deployed. Here's a lobule of aneurysm, some venous bleeding from a small vein under the neck of this aneurysm. Actually, the vein is located here. We'll go ahead and try to stop the bleeding. Obviously indiscriminate use of bipolar coagulation should be avoided. Here's the atrium of the bifurcation or trifurcation. The vein is isolated and the exact bleeding point found. It's best to remain patient, dissect the space so that the exact point of bleeding is identified. The bleeding appears to originate from here. Again, most likely at per Sylvian vein. I left this portion of the video intentionally unedited. So the management of annoying bleeding around the neck can be better illustrated. Unfortunately the bleeding point was not created early identifiable. Here you can see the area of the trifurcation one M2 another M2 and a third M2. There should be another lobe associated with this aneurysm was slightly pointing superiorly is ultimately the bleeding point was found and stopped. The temporary clip was removed and a few minutes of reperfusion allowed. The temporary clip was then reapplied around the M1. Again making sure that the clip is clearly around the entire caliber of the M1. Now this dome better defined and mobilized. Here's another portion of this dome. Small adhesion to the neck of aneurysm were released. Although the aneurysm does not appear large, its morphology is quite complex in the presence of an MCA trifurcation. Let's go ahead and now find the neck of aneurysm around the more dominant M2 trunk, sharp dissection is the best method of dissection in the presence of a ruptured aneurysm, here is another dome of this aneurysm essentially located in the axilla of two of them, two trunks. The anatomy around this lobule is better recognized. You can see some amount of bleeding in from another vein, here's the atrium of the bifurcation or trifurcation now the morphology of the aneurysm is much more understandable. I placed a fenestrated clip or an angled clip. Neither one appeared ideal. Therefore a straight clip was used to occlude the superior lobule of the aneurysm. It was a repositioned for more effective exclusion of the sac. Here's the final position of the clip lights. Next the second lobule of the aneurysm has to be addressed, this lobular period very small. And I did not want to compromise the aluminum of the M1 trifurcation using this second clip. Therefore a very small clip was used to exclude this smaller dome. Here you can see the straight clip collapsing, sac of this aneurysm. There's no residual lobule. The results appear quite satisfying. Here's the ICG angiogram. There's some minor filling of the latter aspect of the small aneurysm. Therefore additional straight clip is needed. Patency of all the three M2 branches was confirmed, here's the final straight clip to close small entry of blood into the smaller lobule. The larger superior lobule is well secured. No other bulbous pathological structure is apparent postoperative 3D angiogram demonstrated complete exclusion of the aneurysms. And three months MRI revealed no evidence of ischemia. This patient made an excellent recovery and subsequently returned to college and finished her PhD. Thank you.
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