Intraoperative aneurysmal hemorrhage during dissection of the neck of the aneurysm is most likely related to aggressive blunt. Dissection maneuvers or fighting the aneurysm that is not adequately deflated via temporary occlusion. Let's review the case of a 42-year old female who presented with a sudden onset of headache and had a six-millimeter left sided rupture MCA aneurysm. On the CT angiogram, she harbored an anteriorly and inferiorly pointing MCA aneurysm. The dome where the aneurysm was closely adherent to the dura over the medial aspect of the sphenoid wing. This adherence is quite important during dissection as aggressive and manipulation of the neck in an aneurysm whose dome is adherent to the dura can be risky since the dome can be avulsed leading to intraoperative hemorrhage. Let's review the events during the operation. This lady unfortunately suffered from a significant amount of subarachnoid hemorrhage. The MCA tree was dissected within the Sylvian fissure from the distal to proximal trajectory. You can see the neck of aneurysm, from here to here the frontal M2 branch and the temporal M2 branch and the temporary clip on M1. Due to adherence of the dome of the aneurysm to the dura, I expected that placement of eclipse can potentially pull on the dome and lead to intra-operative hemorrhage. And therefore preemptive maneuver in the form of placement of temporary clip seemed appropriate. Here is the dome. You can see one of the M2 branches, that temporal one, the frontal one, across from each other. The temporary clip is on the M1. Here is the M1, M2 and another M2. So that aneurysm dome was dissected carefully. So during clip placement, it is not under significant tension. So the dome is not placed under any significant traction. Here again, you can see M1, M2, M2 branch and the neck of the aneurysm that is being circumferentially dissected for placement of the blades. During dissection of the neck, I noted some brisk bleeding from the aneurysm that you will see in a moment. Under temporary occlusion, still the aneurysm contains significant amount of turgor. You can see it's now deflated because of its rupture. It's quite possible that during the dissection, the dome still was not adequately released from its attachment point. And therefore the traction on the dome led to intra-operative hemorrhage. The temporary clip obviously remains on M1. There is fair amount of retrograde flow that is obscuring the operative field. It's best to use suction and remain calm. Clear the field as much as possible while placing the clip to close the dome. You can see the dome is avulsed, it was reflected anteriorly, a portion of it. I placed it straight clip across in a covey aneurysm. There is none much dome left, barely and neck was available for clipping. Further inspection actually reveals a good clip ligation of the aneurysm without any complicating features or compromise of the surrounding branching vessels. You can see the ICG and fluorescent angiography and a comparison of both. Very little dome left. Postoperative angiogram demonstrated an adequate clip ligation of the aneurysm without any complicating features. So the learning points are the importance of identifying the attachment points of the aneurysm dome preoperatively and planning for control of intraoperative hemorrhage, and more importantly, releasing the dome of the aneurysm before clip application, in order to avoid any traction on the dome during deployment of the clip blades. If interpretive rupture occurs, it is obviously best to maintain the operatives composure and clear the field with suction and place a clip as safely as possible to close the neck with the plans to reposition the clip if necessary. Blind placement of the clips, only places to adjacent perforating vessels at risk and is not advised. Thank you.
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