MCA Aneurysm: Clip Repositioning

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Let's rereview some of the basic principles for clip ligation of MCA aneurysms and discuss the worth of interoperative flourescence techniques. This is a 61 year old female who presented with an incidental eight millimeter, right-sided MCA aneurysm. The aneurysm is projecting inferiorly. Sylvian fissure was dissected widely. Here is the distal end of M1. The aneurysm should be projecting inferiorly into the temporal lobe. Here is the neck of the aneurysm. Here's the circumferential neck of the aneurysm. Straight clip would be a perfect option. Temporary clip was placed on M1 for a short period of time. Making sure they clip is across the entire caliber of it, M1. Next, the circumference of the neck was isolated so that the clip lights can be passed uneventfully. Here's the other trunk. Straight clip was placed. It appeared initially that the clip is collapsing the entire neck of the aneurysm. Here you can see the origin of the M2 trunk. Aneurysm appears deflated, somewhat. Let's go ahead and do an ICG angiogram. I can see the aneurysm is unfortunately still filling. There is some spaces within the aneurysm, even though the contrast is somewhat clearing through the vessels. Most likely there is some residual neck at the tip of the blades. Since the aneurysm is not atherosclerotic, therefore the clips are closing completely, but as you can see, there is some residual neck. Subsequently the clip was advanced. Another ICG angiogram demonstrated complete exclusion of the aneurysm with patency of the surrounding vessels. Penetrating the aneurysm revealed again, no evidence of flow within the sack. Postoperative angiogram, again, confirmed complete exclusion of the aneurysm and a CT scan revealed no evidence of ischemia and this patient made an excellent recovery. Thank you.

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