This video describes other variations in clip ligation of MCA aneurysms. This is a 40-year-old male who presented with an incidental 8mm left-sided MCA aneurysm. Imaging demonstrates the typical morphology of the aneurysm and its relationship to the M2 trunks. Patient subsequently underwent a left front temporal craniotomy. The thick superficial arachnoid pens were dissected. Jeweler forceps were used to further split and gently evolves the superficial arachnoid layers. Next, the spreading action of the bipolar forceps were used to dissect the fissure from inside to outside. The aneurism was exposed at the depth of the fissure. Here, you can see the dome of the aneurism I suspected M1, most likely will be found along the posterior. Circumference of the aneurysm, due to the morphology of the M1 on preoperative imaging. The aneurism was circumferentially dissected so that the M1 can be safely found without traction on the dome of the aneurysm. You can see the M1 is not apparent anteriorly. Therefore I gently mobilize the aneurism and try to identify the M1 for proximal control. Due to the turgor of the aneurysm, I had to dissect a little bit of the brain to be able to obtain a better view around the belly of the aneurism. The M1 should be located just about there. Here's a better view of the M1 after a gentle mobilization of the sack anteriorly, here's the M2 branch, here's another M2 branch. Now that proximal control is secured, I can continue with further dissection. Here's more mobilization of the aneurysm along its anterior belly. The neck of the aneurysm is also better defined. Here is adequate identification of M1 for placement of a temporary clip. So the aneurism can be slightly deflated and more precisely clipped. Here you can see the aneurysm is more deflatable. I continue to carefully dissect the circumference of the neck. Here is a curved clip. Appears to be across the entire neck of the aneurysm. A second clip was placed just to provide some assurance. Appears the neck is well secured. Here is intraoperative ICG that demonstrates complete exclusion of aneurism but maybe small filling of the aneurysm at the dome. The second clip was advanced further. You can see the refilling of the aneurysm. Second clip is being advanced towards the more distal neck of the aneurysm Here's penetration of the aneurysm sack. Reveals no further filling of the aneurysm. Postoperative angiogram demonstrated reasonable clip ligation of the aneurysm without any evidence of schemia and this patient made an excellent recovery. Thank you.
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