Let's talk about simultaneous clip ligation on a ruptured MCA, as well as an anterior communicating artery aneurysm. This is a 61 year-old female who presented with a ruptured left MCA and an unruptured incidental anterior communicating artery aneurysm. You can see the distribution of the blood primarily over the left Sylvian fissure. The location and the broad base of the aneurysm is demonstrated on this 3D reconstruction CTA angiogram. Furthermore, the sagittal CTA image demonstrates the anterior communicating artery aneurysm, which is pointing inferiorly. She underwent a left front-end temporal craniotomy. Sylvian fissure was widely dissected, there was dense amount of blood. The brain was relatively tense. Despite range of CSF from the optical carotid cisterns, the brain remained somewhat swollen. After the initial stages of the dissection were completed, I felt that an external ventricular drain would be beneficial. Here again, you can see the swollen Sylvian fissure, very adherent due to the presence of the blood. Hydrodissection of the fissure did not appear to help. Therefore a left frontal burr hole was created and an external ventricular drain was inserted into the frontal horn. You can see the perpendicular trajectory of the drain guiding insertion of the catheter into the ventricle. CSF was obtained immediately. Here you can see the dissection of M1. The brain now was much more relaxed after drainage of the CSF. After temporary occlusion of M1 was achieved, the dome of the aneurysm was uncovered. I had to circumferentially dissect around the entire neck of the aneurysm to be able to make sure the clip is appropriately placed. This maneuver was required since the aneurysm was quite broad-based. Sharp dissection was utilized, again to mobilize all the adhesions to the dome of the aneurysm. After a two-minute period of reperfusion, the temporary clip was reapplied. In the presence of the temporary clip you can see the aneurysm sac is quite relaxed. The neck of aneurysm against the M2 branches is thoroughly dissected. Slightly curved clip was deployed. This one appears to be slightly short. Longer one was utilized. Again, preserving the atrium of the MCA bifurcation. Temporary clip was removed. Aneurysm appears to be well excluded. Clip blades are across the entire neck of the aneurysm. A generous atrium was left behind. Micro-Doppler ultrasonography revealed patency of the branching and parent vessels with complete exclusion of the aneurysm sac. Next, dissection continued along the subfrontal area, just over the optic nerve and chiasm. The anterior communicating artery aneurysm was readily exposed. Here's A2, A1 ipsilaterally. The aneurysm sac. Can see the multi-lobe nature of this aneurysm with evidence of atherosclerosis at the dome. Here again, you can see the A2. Now the contralateral A2 was also dissected. Again A1 proximally, A2 ipsilaterally. Again, looking across the dome of the aneurysm to find the contralateral A2. Perforating vessels were mobilized. Here you can see the contralateral A2 there. Using dynamic retraction to mobilize the perforator, identify the contralateral A2, ipsilateral A2, contralateral A2 just behind it. Here's a straight clip. This is a relatively straightforward clipping because of the inferiorally pointing nature of the aneurysm. Clip appears to be across the entire neck of the aneurysm. Fluorescein angiography revealed patency of the perforating vessels, as well as the branching vessels with complete exclusion of the aneurysm sac. Here's the funnel view of the operative corridor. Postoperative angiogram further confirmed complete exclusion of both the MCA and ACom aneurysms. Thank you.
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