This video describes clip ligation of a large atherosclerotic MCA aneurysm and anterior temporal artery aneurysm within the same patient who presented with subarachnoid hemorrhage. Here's the CT angiogram. Again, they were large middle cerebral aneurysm, smaller anterior temporal artery aneurysm, and an Acom aneurysm, which was determined to be unruptured based on the pattern of blood. However, it was explored intraoperatively and was noted to be too atherosclerotic for a clip ligation. Here's the dissection of the right Sylvian fissure, and one was dissected and a temporary clip was placed on it. Here you can see the very broad base anterior temporal aneurysm. The origin of the anterior temporal artery should be recognized. Most likely it's more proximal. Here we can dissect around the entire circumference of the neck before the clip blades are deployed. You're looking behind the neck of the aneurysm. We'll go ahead and place a clip on this one after further dissection posterior to the neck is carried out. Again, you can see the sharp dissection using micro scissors. You can see the origin of the anterior temporal artery right there at the tip of the clips. Here are the clip blades. After that aneurysm had been taken care of, we moved on to the large MCA bifurcation aneurysm. It was adequately mobilized. The neck was circumferentially dissected under temporary occlusion of M1. The aneurysm is very deflated. It's very important to circumferentially isolate the neck and recognize all the M2 branches so they are not inadvertently placed within the clip blades. You can see presence of atherosclerosis at the neck of the aneurysm. This means that we have to leave some neck behind in order to protect the safety and patency of the bifurcation intraluminally. Temporal M2 branch. Atherosclerotic neck. Obviously, multiple clips are necessary for exclusion of this aneurysm safely. The atherosclerotic neck most likely won't collapse using a single clip. Here's the first clip application. Curved one. Again, staying away from their inlet and outlet of the adjacent normal vessels. Leaving some neck behind in order not to compromise the bifurcation intraluminally. Micro-Doppler probe is used to assure patency of the bifurcation vessels. The clip is mobilized a little bit further incorporating this nodule of the neck. The frontal branch apparent here. As the patency of the vessels was not clearly Dopplerable, we'll go ahead and reposition the clip. Again, this time slightly away from the area of the bifurcation. Here, you can see the temporal branch, frontal branch bifurcation atherosclerosis. Again, Doppler device is used for immediate verification of the patency. There is some flow present, although not sure if it's adequate. The aneurysm appears to be faintly filling. We'll go ahead and apply the temporary clip again. This time, again, moving further away from the neck, gathering the aneurysm with this suction into the clip blades. Assuring that the clip blades span in the aneurysm. Again, looking around the entire circumference of the neck to provide a better understanding of the anatomy. Now that the flow was adequate, we'll go ahead and stack our other clip blades. Again, using the tandem clipping technique. This time, closing the distal neck with a straight Fenestrated clip that has excellent closing pressure more distally. Other clips further augment the initial clips. We want to make sure that the clip blades don't overlap. Again, continuously confirming good flow within the M2 branches. Now that the adequate exclusion of the aneurysm was secured, I'll go ahead and explore the Acom aneurysm. This aneurysm appeared very atherosclerotic. There was no clear neck that could be clipped without incorporation of the atherosclerosis. And therefore we felt that this aneurysm is more fitted for intravascular coiling. Here is the fluorescein and ICG angiograms demonstrating complete exclusion of the anterior temporal artery aneurysm, as well as the MC bifurcation aneurysm. Here, you can see the MC bifurcation is completely non-filling. All the parent vessels were filling nicely. Here's the final product of the brain, appears healthy, and here's the postoperative CT, which did not reveal any evidence of ischemia. A 3D angiogram after surgery revealed complete exclusion of the aneurysms without any complicating features, and this patient made an excellent recovery. Thank you.
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