Complex MCA Bifurcation Aneurysm

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This video is a nice example of the critical importance of sound judgment and intuition for confirming that the aneurysm is completely excluded before the operation is completed. This is a 51 year-old female who presented with a left-sided sylvian hemorrhage. CT angiogram demonstrated as superiorly pointing relatively proximal MCA bifurcation aneurysm, left-sided frontotemporal craniotomy was accomplished. You can see that there's some more clot within the subarachnoids space, Sylvian fissure was widely dissected, hemorrhage was evacuated in the proximal M1 was identified early. Early identification of the MCA is important. Here you can see the neck of the aneurysm. I went ahead and secured proximal control, curved temporary clip was used next to the aneurysm neck was dissected. You can see the location of the aneurysm here. Again this is still M1. Sharp dissection was used. Here again is the distal neck aneurysm, M1, more distal M1 the neck of aneurysm lenticular straight arteries were carefully protected. After a period of re-perfusion, the temporary clip was replaced, or you can see the location of our lenticular straight artery. Here's underneath the neck of aneurysm. I was relatively happy with the exposure of the neck, looking all the way across the aneurysm, both superiorly and inferiorly. I'm ready to deploy the clip. Here's a straight clip across the entire neck. This was repositioned to make sure the clip spends the entire neck of the aneurysm. Here's the ICG. There was a suspicion of potentially the sac is still filling, here you can see just rare plash or fluorescence. I suspected that clipping is not adequate. Therefore further dissection was completed. Here you can see the aneurysm was completely mobilized. Here's the dome temporary clip was placed. You can see the aneurysm is very suboptimally clip litigated. Therefore, the neck was further dissected. Circumferential exposure of the neck was performed. Here you can see actually a branch was included in the clip and another perforating branch here. You can see how suboptimally the clip was deployed. Bipolar coagulation of the neck was completed to gather the aneurysm, next an angled clip was used. You can see that the neck is completely excluded with preservation of all the adjacent parent vessels. Here's another look and one and two branches complete exclusion of the aneurysm. Here's another look of our clip reconstruction and postoperative angiogram demonstrated complete exclusion of the aneurysm. And to CT scan only demonstrate a slight amount of retraction. The mind in this case the brain was quite swollen. This patient made an excellent recovery. Again this video demonstrates the importance of adequate inspection of the neck after the clip is deployed to assure that the aneurysm has completely excluded. Any blind placement of the clip can lead to compromise of the surrounding vessels and suboptimal clip ligation of the aneurysm sac. Thank you.

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