MCA Aneurysm Associated with a Hematoma

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Clip ligation of MCA aneurysms that are associated with a temporal lobe hematoma can be quite challenging since the hematoma can distort normal anatomy, and interfere with adequate, and early exposure of the MCA. This is a 61 year-old male who presented with sudden onset loss of consciousness. CT scan demonstrated a large temporal lobe hematoma with evidence of significant mass effect and midline shift, and MCA aneurysm at the level of bifurcation pointing into the clot, was diagnosed. The patient was subsequent taken to the operating room emergently for evacuation of the clot, and clip ligation of this aneurysm. Here's the opening of the dura, Sylvian fissure, a corticotomy within the superior temporal gyrus was completed to evacuate the hematoma, decompress the brain, and clip ligate the aneurysm. Is removal of the clot, aggressive removal of the clot should be avoided, so that premature rupture of the aneurysm can be minimized after evacuation of the clot. The M1 was found within the arachnoid bands of the Sylvian fissure, after the M1 was clearly identified, dissection continued more distally along the MCA. The arachnoid bands, of the Sylvian fissure were dissected, and the aneurysm neck was identified. This transsylvian approach may not provide an adequate space for adequate evacuation of the hematoma early on, and therefore I prefer a small gyral incision within the superior temporal gyrus to evacuate the hematoma. So here is the aneurysm, here are the M2 branches clearly identified on both sides of the neck. Aneurysm appears somewhat multilobulated, curve clip was used, to close, and collapse the neck of aneurysm while preserving the M2 origins, also preserving the atrium of the MCA bifurcation. Temporary clip was subsequently removed. De-magnified view of our operative corridor. The micro-Doppler was used to inspect the flow within the aneurysm, and the branching vessels. Further inspections reveals no compromise of the approximal M2 branches. Here's an ICG angiogram confirming our findings of clip ligation of the aneurysm sac, and patency of the M2 branches. The M1 is also patent. I'm satisfied with the results of our clip ligation. More of the temporal clot now can be removed generously. So adequate decompression of the brain can be secured. Post-operative angiogram revealed adequate clip ligation of the aneurysm. An additional clip, as you can see, was added to the first one to make sure that complete exclusion of the neck is secured. Adequate hematoma evacuation was also confirmed, and this patient made an excellent recovery, and his hemiparesis significantly improved immediately after surgery. Thank you.

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