MCA Aneurysm Associated with Hematoma, 3M2

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This short video describes clip ligation of small MCA aneurysms, associated with a temporal intracerebral hemorrhage. This is a 47 year old male, who presented with a sudden onset loss of consciousness. Was evaluated. A CT scan demonstrated a large, temporal intracerebral hemorrhage, associated with a small right-sided, middle cerebral artery bifurcation aneurysm. Right frontotemporal craniotomy was completed. A quart-economy was performed within the superior temporal gyrus to evacuate the hematoma as thoroughly as possible, without disturbing the dome of the aneurysm. After the hematoma was relatively well evacuated, I dissect the Sylvian fissure, looking for the M1 branch. The arachnoid membranes, over the fissure are first encountered, via dissection through this superior temporal gyrus. These arachnoid bands are opened. Here, are the M2 branches within the fissure. Obviously, I'm going to skip the area of the dome, and direct my dissection more anteriorly so, that the M1 can be found. Here's the distal part of the M1 available for proximal control. This vessel was circumferentially isolated for placement of a temporary clip. Here's placement of the temporary clip so, more definitive dissection around the neck of the aneurysm can be pursued. Here's the aneurysm. One has to always be aware of the possibility of trifurcation, as you can see here. So, this is one M2, another M2 and a third M2. Obviously, all three branches must be protected. Straight clip was applied across the neck of the aneurysm. All three M2s were noted to be patent on micro-Doppler ultrasonography. The clip was slightly repositioned, to make sure the flow within the third M2 is plenty. I'm happy with the configuration of the clip at this point. I see the angiogram confirms complete exclusion of the sack and patency of the three M2 trunks. Post operative CT scan confirmed adequate evacuation of the hematoma, without any evidence of ischemia. Furthermore, the angiogram confirmed complete exclusion of the aneurysm. Thank you.

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