This video is a nice example of a large atherosclerotic MCA aneurysm, and also describes the importance of false negative fluorescence during the surgery. This is a 65-year-old male who presented with subarachnoid hemorrhage. CT angiogram demonstrated this very broad ways, right-sided MCA aneurysm. He underwent a right frontotemporal craniotomy. The fake superficial arachnoid bands of the Fischer were sharply dissected. As I have described in my other videos related to this sylvian fischer, I like to use the jeweler forceps to gently disconnect the superficial arachnoid bands, this technique works well while preserving the draining veins over the Fischer. The inside to outside technique was next used to find the M2 branches and follow them to the aica aneurysm. Here's the use of the inside to outside technique. Finding those in two branches, again dissecting from inside to outside. Here's a peak of the dome of the aneurysm or slightly here's the aneurysm sac and M2 branches. Operative trajectory is maintained over the vessels. Here's the aneurysm quite sizeable. I continued dissection over the neck of the aneurysm until the M1 is exposed for vascular proximal control. The sac is quite tense. Obstructing our operative view. Here's identification of the M1 at the pace of the aneurysm. Some of the lateral lenticular straight arteries are also evident. Temporary clip was placed on the distal M1 under per suppression. This maneuver will allow mobilization of the aneurysm and identification of the other M2. Bipolar coagulation of the dome was necessary in order to mobilize the aneurysm out of our view so that the clips are properly placed while preserving the origin of the other M2 as you can see at the tip of the arrow. Because of the dense atherosclerosis of the aneurysm neck, tandem clipping technique was used via a combination of straight and fenestrated clips. Multiple clips were utilized. I felt that I'm all the way across the neck of the aneurysm. Here's the origin of the other M2, which appears spared from the tip of the clips. I felt that one of the clips could be placed a little deeper or closer to the contralateral M2. You can see the use of the mouth switch to facilitate movement of the microscope, while the surgeon continues the ambidextrous dissection. Here's additional straight clip, just to make sure that the part of the aneurysm through the fenestration of the distal clip is completely collapsed. Micro doppler auth sonography did not reveal any evidence of filling of the sack. All the vessels were patent, the aneurysm appeared completely excluded. However, placing a needle within the sack reveals that the aneurysm is continuing to fill. Here's an example, again of false fluorescence on highly atherosclerotic aneurysms, therefore, some of the clips were advanced further because I felt that the most distal part of the neck of the aneurysm is most likely not completely collapsed. This adjustment led to cessation of bleeding from the aneurysm dome. In this case, the post operative angiogram reveal of complete exclusion of the aneurysm using a number of the clips and this patient made an excellent recovery. Thank you.
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