October 28, 2019
This is another video describing the classic clip ligation strategies for MCA aneurysms. This is a patient who presented with history of subarachnoid hemorrhage and bilateral MCA aneurysms. The right-sided ruptured aneurysm was managed previously three months before and now she return to the hospital for clip ligation of her left-sided aneurysm. Pushing on the one to left front temporal craniotomy, left frontal lobe, temporal lobe, Sylvian fissure. The superficial arachnoid was incised using around arachnoid knife. Salient injection may be used to expand the fissure and a low, easier dissection along its planes. Here's a small vein superficially that was sacrificed. Then we'll go ahead and resume the inside to outside technique to be able to expose the aneurysm. You'll see a relatively minimalistic approach. In this case, for dissecting the fissure one has to be careful that this minimalism would expose all the M2 branches and all the surrounding branching vessels, so they are spared from the clip plates. Here, again, the inside to outside technique, going deep initially, and then coming superficial until the fissure is completely open. Previous history of subarachnoid hemorrhage in this case made the fissure very difficult to dissect. Using micro scissors for sharp dissection until the M2 branches are identified and follow it to the MCA bifurcation and the neck of the aneurysm. Here we can see the area that bifurcation and location of the aneurysm. Go ahead and work obliquely parallel to the surface of the Sylvian fissure. You can see use of dynamic retraction in this case. The fissure in this patient is quite steep. Using the spring action of the bipolar for dissection here, you can see the neck of aneurysm, M2 branch, most likely temporal branch. Here's a temporary clip on distal M1 to dissect the neck of the aneurysm more thoroughly. Here's placement of the clip across the neck of aneurysm. Here's a straight clip. You can see the neck is relatively broad in atherosclerotic. So I stayed a little bit away from the bifurcation area, just so that the bifurcation is not compromised due to that atherosclerosis at the neck of aneurysm. Temporary clip was removed. Fluorescein angiography was performed, which confirmed patency of their surrounding vessels and complete exclusion of the aneurysm. You can see the vessels, the aneurysm is not filling at the tip of the arrow. All the small perforators are patient. Temporal lobe is filling nicely. Here's the aneurysm, is opaque. Here's the final product. The brain appears very healthy, very small opening. And here's the postoperative angiogram demonstrating complete exclusion of the aneurysm, patency of the vessels. No evidence of ischemia on the CT scan. And this patient made an excellent recovery. Thank you.
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