Complex MCA Trification and PCoA Aneurysms

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This is an interesting case of a complex MCA bifurcation and a simple PCoA Aneurysms. This is a 52 year old female who was diagnosed with 2 incidental aneurysms, one at the level of the left MC bifurcation. As you can see on the axial CT angiogram image, as well as small PCoA Aneurysms. The preoperative coronal and sagittal CT angiogram images did not reveal the presence of the trifurcation at the level of the MCA aneurism. However, the intra-operative findings prove to be otherwise. Patient underwent a left front temporal craniotomy; anterior limb of the seven Fischer was widely dissected. Sub frontal area was released from the optic nerve. Here's the internal carotid artery, a traumatic dissection of the Fisher to reach the PCoA. Here's the initial exposure of the PCoA aneurysms. Then to quote a origin is located at the tip of my arrow to aloe further dissection of the Aneurysm neck from the PCoA a temporary clip was applied to the internal Carotid Artery temporarily Here's the origin or the PCoA. You can see the neck against the origin of the PCoA Straight clip was applied while preserving the origin of the PCoA. Here's the origin of the internal core artery that was preserved. The origin of the PCoA going away from us, is also spirit. The Aneurysm appears to be completely excluded. Next, we focused our attention on the MCA origin. This proved to be a complex one, you can see the blister aneurysm around the neck of the aneurysm, which complicated clip application here's M1, one of the M2's. The entire neck of the aneurysm should be meticulously dissected. One of the perforating vessels or smaller arteries was mobilized away from the aneurysm. Small amount of bleeding was controlled using a piece of cotton soaked and thrombin and gentle tamponade. cotton was removed now. I had to expose more of the dome in this case, to be able to assure myself that all the M2 branches are spared, during the application of the permanent clip. You can see the aneurysm sack is quite thin in its wall, and other adherent vessel to the dome of the aneurysm is a parent. Here's another M 2. However, further dissection revealed the presence of a third and 2 just around the posterior wall of the aneurysm neck. This case clearly demonstrates the importance of meticulous circumferential aneurysm dissection before the permanent clip has applied and other look at the morphology of this aneurysm. After 2 minutes of re-perfusion, the temporary clip was reapplied and further circumferential dissection carried out. You can see that third M2 going away from us. Warn him to the other M 2 First I attempted a straight clip, that didn't appear to be the right one, felt that additional dissection is necessary so that the clip blades can be advanced under direct vision. So the neck of the aneurysm, and it's, dome is further dissected so I can have adequate visualization around the neck of this relatively small aneurysm, short dissection was used to mobilize another adherent branch. The presence of the atherosclerosis, also complicated clip application because the clip plates can potentially compromise the origin of the third M2, if they're not applied exactly at the right position. And more satisfied now with a dissection, you can see both M 2s on that side. There is one the other one on 2. I wanted to reduce the aneurism mid body, just a bit with bipolar, quite relation. Aneurysmal Rafi, so, I'm able to pass the clips more effectively while focusing my attention along the tip of the blades curve clip appear to be a good choice. I wanted to make sure I grab and insert the entire portion of the blister aneurysm into the blades. Here. You can see manipulation of aneurism into the blades to assure that the entire thin wall of the neck is incorporated. First view reveals that the clip is slightly short. This M2 is preserved. However, the other M 2 is located just about here. Still some inlet into the aneurysm is potentially pleasant. I can be too close to the origin of this M 2 because of the presence of atherosclerosis. So I advanced the clip just a little bit, but not all the way so that the force of the tip of the clip lights do not collapsed origin of the third M 2. I was relatively satisfied that the tip of the blades are close enough to the origin of the M 2, but not too close. So that the third M 2 remains patent. Here's the tip of the clip blade, close to the origin of the third M 2, but not too close. So that the third M 2 is filling as well. Going around the aneurism, I was able to see the third M2 more effectively. I see angiogram revealed patency of all three M 2 vessels. You can see the third and 2 behind the aneurism. One, 2, three. You're another look at the origin of their third, M 2 and the postoperative angiogram revealed clip ligation of the aneurysm effectively and patency of all the MCA branches that pecan mannerism was also adequately clipped. And there was no inner sort of schema on the post-operative CT scan and the patient made an excellent recovery. Thank you.

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