Let's review one of my older videos from earlier in my career. This is Clip Ligation of MCA Aneurysm and describes techniques for Sylvian fissure dissection. This is a 51 year-old male who presented with left sided six millimeter on ruptured MCA aneurysm. The morphology of aneurism is demonstrated on the CT angiogram on the coronal image you can see that the aneurysm is pointing slightly more superiorly than typical MCA aneurysms do. He underwent a left frontotemporal craniotomy. There were numerous veins along the superior aspect of the fissure. I found the methodology for dissecting these veins is to use jeweler forceps, and gently tear the superficial thick arachnoid bands. This method maximizes the safety for preservation of the veins. The veins are mobilized primarily toward the temporal side. Mike scissors can be used to further dissect these veins, however, the veins can be easily suctioned into their suction device and therefore small piece of cotton may be used to gently hold the veins away. Once the superficial arachnoid bands are released, entry into the sylvian cistern is readily possible. I continue to use sharp dissection as much as possible, and split the fissure from the inside to outside technique. In other words, dissect the fissure deep, distally and then fork from inside to outside to dissect this superficial interior digitations between the frontotemporal or particular. Here's that dissection from deep to superficial, you can see that I'm working deeper into fissure and just moving more superficial. This maneuver is specially important because the deeper Plains or more easily recognizable due to the presence of the arterial structures. I used to use fixed retractors much more frequently than I do today. Here's additional dissection, the aneurysm is demonstrated again point thing superiorly which is relatively unusual for MCA bifurcation aneurysms. The aneurysm is very bright base and does contain some atherosclerosis close to the neck and the dome. Let's go ahead and understand the morphology of this aneurysm a little bit better, you can see the M one is situated deep to the neck of the aneurysm. Here's part of the M one that is readily visualized. You can see some atherosclerosis at the level of the bifurcation. This finding is important, as some extra neck has to be left behind to create an adequate atrium at all the bifurcation to avoid any compromise of the origins of the M two branches. I placed a temporary clip, so I can more readily manipulate the neck, and apply a definitive clip at the neck of the aneurysm, more precisely. So here you can see the atherosclerosis at the level of a dome, the aneurysm is relatively bulbous, it has a blister there. Here's the neck aneurysm, here's a trial of a clip appear to be sliding to their atrium or the bifurcation based on the atherosclerosis at the level of the neck of the aneurysm. Here's a view of the aneurysm without placement of the clip under ICG angiogram, a clip was placed but this time slot that this stall to the atherosclerosis. So the origin of the M two branches are not compromised. Again, perfect clipping in this case, can at least to compromise on the M two branches because extraluminal inspection may underestimate the amount of intraluminal stenosis. Here's another view, again, this is some contrast remaining from the last injection, the new injection demonstrates that the aneurysm is completely excluded, and here's the final result. You can see that carefully dissection preserved most of the draining veins and when the patient harbors such dominant draining veins over the Sylvian fissure, most likely the other veins are not as well developed. And these veins could be very critical for drainage of the hemisphere and should be carefully preserved during the operation to avoid venous infarction. And the postoperative CT excludes any evidence of ischemia, postoperative angiogram demonstrates adequate exclusion of the aneurysm, thank you.
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