This video describes dissection of a difficult fissure in the case of a ruptured MCA aneurysm. This is the case of a 63 year-old male who presented with spontaneous subarachnoid hemorrhage CT scan demonstrates thick amount of blood or clot in the left Sylvian fissure. There is extensive amount of hemorrhage in this area, making fissure dissection relatively difficult, especially in those patients who have had multiple hemorrhages before they present to the hospital, the fissure can be quite adherent and fibrosed making it split quite a challenging task. The CT angiogram demonstrates the relatively proximal location of this MCA aneurysm and a short M1. Therefore a wide dissection of the fissure is necessary to be able to obtain proximal control. Importantly, as you can see, the thick tenacious blood often feels the whole fissure, and one has to use the vessels more than the opercular in order to be able to find the pathway toward the MCA bifurcation. In other words, the MCA branches or the essential roadmaps for the fissure split, let's go ahead and, discuss the findings and surgeries. You can see a frontotemporal craniotomy of right frontal lobe, right temporal lobe. Sylvian fissure quite filled with thick amount of blood. Often it's difficult to even see where to open the fissure. There's fair amount of thick arachnoid here, there may be a good place to start. And even with very gentle opening, often you make it into a vein immediately and hemostasis should be obtained as readily as possible. Here you can see some bleeding from one of the superficial Sylvian vein branches. Again, the thick tenacious blood prevents any easy dice, visualization and inspection of the opercular. After the superficial fissure is open in this case, I continue to work within the tenacious blood. Again, use the combination of gentle blunt dissection techniques as was the sharp techniques for following MCA branches. The opening action or spring action of the bipolar forceps is really a nice technique to gently open the thick tenacious blood, and find the M2 branches, and follow them more proximately. You can see the vessels are cleaned off, and then I continue to evacuate the blood clot. It's relatively easy to get just peal the anterior arachnoid membranes of the fissure. Along this phenoxodiol section are dissected. The veins are protected as much as possible. And then I continue to use the tip of the mitral scissors when closed, as a dissector to work through the tenacious clot here, again, working through until the M1 is exposed. The aneurism should be here. So I'll go ahead and secure proximal control, a template clip was placed. Now I can go ahead and dissect the aneurism. You can see it's pointing superiorly. Most likely there is a branch originating from the base of the aneurysm more proximately. I'll make sure that the pathway for the tips of the blades are created. You can see the straight clip that was applied. I mean, inspecting to make sure the anterior temporal branch is protected in this case, maybe a little bit distal to the anterior temporal branch. So I'll go ahead and reposition it a little bit more proximally. And after that, you can see the intertemporal branches protected, as you can see on fissure and angiography, and the aneurysm is completely excluded. And the final product demonstrates that there is relatively minimal amount of injury to the surrounding brain. Postoperative angiogram demonstrates complete exclusion of the aneurysm without any complicating features, and the intertemporal branches carefully protected. And there is no residual aneurysm. Again, this is a great case to demonstrate the difficulties and challenges that we face dealing with fissures that are filled with blood and can be quite adherent. The blood prevents the easy navigation that you often see for an unruptured fissure, and therefore the vessels remain an important compass to find our way through the fissure, and toward the M1 bifurcation. Thank you, for your attention.
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