April 21, 2016
Let's review some of the strategies for managing M1 or medial lenticulostriate artery aneurysms, and more specifically, handling atherosclerosis at the neck of these aneurysms. This is a 42 year-old female with an incidental left-sided five millimeter M1 aneurysm. The morphology of the aneurysm is apparent on this 3D arteriogram. The medial lenticulostriate artery is originating and emerging from the neck of this aneurysm. Due to her family history of ruptured aneurysms, went to left-sided frontotemporal craniotomy. Frontal lobe, temporal lobe, dynamic retraction is utilized for exposing the distal M1 territory. Here's the area of the bifurcation. Here's the distal M1. Here's the distal neck of the aneurysm. I'll go ahead and seek for the location of the perforating vessel, that was, or is, emerging from the neck of the aneurysm. Here's this perforating vessel. Here's a more magnified view of the perforating vessel that is branching off immediately after it comes off the neck of the aneurysm. There's also some atherosclerosis at the neck of the aneurysm based on the discoloration in this area. I'll go ahead and circumferentially isolate the neck of the aneurysm so that the clip blades are deployed effectively and not blindly. Obviously the clip blades have to sit just distal to the origin of the perforating vessel. This case a temporary clip was placed across the ICA, so that the aneurysm sac can be more manipulated safely. Initially used a mini clip. The clip continued to slide due to the lower-causing pressure of the mini clips. To avoid the displacement of the clip blades, next I tried a regular short clip blade. This case the regular clip has a more exaggerated closing pressure. This clip did not slide toward the neck of the aneurysm. Intraoperative fluorescein angiography, as well as ICG, revealed patency of the perforating vessel, without any further filling of the aneurysm. Here's the final result, using a traumatic dynamic retraction. Postoperative CT scan revealed no complicating features related to the clip ligation of this aneurysm. Thank you.
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