August 13, 2016
Appropriate management of intraoperative misadventures makes the most difference in the outcome of our patients. This video describes repair of a tear in the wall of the M1 segment during clip ligation of ruptured MCA bifurcation aneurysm. This 52 year old female who presented with a sighted stubble right side of temporal hematoma, as demonstrated here associated with a small ruptured MCA bifurcation aneurysm. She underwent a right side of the front temporal craniotomy. The superior temporal gyrus was entered so that the hematoma can be evacuated, readily, brain relaxation obtained, and the M1 exposed. The initial steps of the operation were performed by one of my fellows. Microsurgical dissection continue to expose the M1 through the arachnoid bands of the Sylvian fissure. Some bleeding was encountered. A temporal clip was applied to the bleeding point. Next I enter the operative field. I was planning to inspect the bleeding point and obviously expose more of the adjacent cerebrovascular anatomy. The M1 was still covered with fair amount of arachnoid bands. Here's the more distal part of the M1. I continue to dissect the artery a little bit more proximately. That bleeding point was more uncovered during this maneuver. You can see that the hole within the M1 is relatively large piece of cottonoid. Allowed some control of the bleeding. Proximal control is necessary in this case. I was unable to apply a temporal clip, right at the area of the defect. Piece of cotton was used so that the bleeding can be temporarily controlled and the proximal control secured. Here's another look at the defect in the wall of the M1. Now that a temporary clip is applied further dissection can continue. Here's one of the lenticular striate arteries that should be preserved during repair of the defect. The most important part of the plan is to carefully inspect the surrounding vascular anatomy so that an appropriate plan can be devised. Here's the more proximal segment of the M1 leading to the ICA. Temporal clip was repositioned. And another look at the defect in the wall. Finally, I used a curved permanent clip to close the defect while preserving the lumen of M1. Here's placement of a permanent clip, micro-Doppler ultrasonograph revealed patency of the adjacent vessels. I continue dissection distal on M1 until the aneurysm was exposed at the level of the bifurcation. Permanent clip was placed across the neck of the aneurysm. Here is one M2, here's another M2, the neck of the aneurysm. Ultimately this permanent clip had to be repositioned so that the entire neck of the aneurysm is within the clip blades. I further inspected his adjacent anatomy to make sure a trifurcation is not present. However, in this case, a trifurcation was apparent as you can see here. However, the clip spared the third M2. Intraoperative fluorescein angiography revealed patency of the M1 and M2 branches here with obliteration of aneurysm sac. Here's a more de-magnified view of our operative field. Additional pieces of the blood clot were removed within the posterior temporal lobe for further brain relaxation. Postoperative CT scan revealed relatively good decompression of the hemisphere. Some blood within the descending motor tracks was left intact to avoid any injury to these ascending tracts. Postoperative angiogram demonstrated complete exclusion of the MC bifurcation aneurysm. You can see that the curve clip was able to adequately close the defect without compromising the lumen of the M1 and this patient eventually made an excellent recovery and her hemiparesis resolved. Thank you.
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