MCA Aneurysm Associated with a Sylvian Clot

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This video describes the methodologies for clip ligation of MCA Aneurysms associated with a sylvian clot. This is a 65-year old female who presented with a small right-sided ruptured MCA aneurysm. On a CT angiogram you can see the thick layers of clot within the sylvian cisterns associated with this very small right-sided MCA aneurysm. The patient underwent a right frontotemporal craniotomy. You can see the thick clot associated with this aneurysm. One has to be very careful during mobilization of the clot to avoid premature intraoperative rupture via transmission of the traction to the dome of the aneurysm. My strategy involves following the M2 branches carefully proximately while remembering the projection of the aneurysm and avoiding any dissection directly toward the dome of the aneurysm. In this case the aneurysm was slightly pointing posterially therefore I kept most of my dissection along the intro aspect of the fissure. Sharp dissection was used to dissect the clot. I did not pull on the clot too aggressively so that the forces are not transmitted to the dome of aneurysm. Here you can see one of the M2 branches that has been followed toward the M1. so that proximal control is secured and more distal dissection toward the neck can be accomplished. Here again you can see the thick fibronous clot has been sharply dissected. Here is working through the clot can be vein. Being very careful but not ending up directly on the dome of aneurysm inadvertently The branches of the MC are carefully isolated and sharp dissection is used as much as possible. Again here are the M2 branches. The M1 branch is now apparent. Now that proximal control is secured I can continue to dissect the clot more distally so that the aneurysm can be exposed. Here's the bifurcation M2 trunk, M2 trunk, and the aneurysm. Again the clot is left over the dome to avoid premature rupture. The temporary clip is placed on M1 so that the neck on the aneurysm can be circumferentially identified. And a straight clip would easily exclude this aneurysm without difficulty. Again it's important to remember the map of the vasculature to avoid inadvertent arrival to the dome of the aneurysm unprepared. Aneurysm appears to be completely excluded after it's been more dissected upon its definitive clip ligation. You can see the intraoperative ICG confirmed complete exclusion of the aneurysm and the postoperative angiogram. Furthermore confirmed the complete ligation of the inner aneurysm sack. Thank you.

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