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MCA Aneurysm: Importance of Intuition

October 28, 2019

Transcript

This is another video describing the standard techniques for clip ligation of MCA aneurysms, and more specifically, the use of intuition. Surgical intuition is very difficult to define, but I do believe plays an important role as one's experience develops with minimizing the risks of surgery. This is a 62 year-old female with an incidental aneurysm found on surveillance imaging for headaches. You can see this MCA aneurysm relatively broad base, multilobulated. Let's go ahead and explore this aneurysm. This patient underwent frontotemporal craniotomy in right-sided approach. You can see the temporal lobe, frontal lobe, the inside to outside technique. The aneurysm was easily identified with minimal injury to the frontotemporal operculum. See the aneurysm there, following the M2 branches to the base of aneurysm, here, tip of the arrow using mark surgical techniques and avoiding the fixed retractors as much as possible. Finding the M1 early on to secure proximal control, as you can see here. Nice, control the M1 there. I'll go ahead and circumferentially identify the M1 so that a temporary clip can be placed there. Here's the base of the aneurysm. Appears that it's ready for clip application. Clip was initially placed by one of my colleagues. Clip appears to be all the way across. Maybe a little bit short after further inspection. Nice view of the anatomy. All the vessels that are within the operative field appear patent. However, the aneurysm appear to be filling. He went ahead in advanced to clip plates to make sure that the aneurysm is completely occluded. And then Micro-Doppler was used to inspect the area. This time the aneurysm did not appear to be filling the other branches where in the anatomy is very evident. There is some atherosclerosis. Here you can see the complete occlusion of the aneurysm and patency of the surrounding vessels using fluorescein angiogram. The next steps are quite important. And again, that's what I'm referring to surgical intuition, is one has to inspect their aneurysm and make sure that the plates are not affecting any of the arteries that could be hiding besides the neck of the aneurysm. In this case, I just wasn't sure that the aneurysm is the only structure that was affected by the clip. Therefore, I inspected the dome of aneurysm. You can see there is a vessel behind the dome, And I followed the vessel. And here you can see that there's actually a temporal branch that's completely occluded by the clip plate. So I remove the clip naturally. Dissect the aneurysm as much as possible from the temporal branch. And now the true neck of the aneurysm is ready for a clip application. If the inspection had not occurred and this vessel was not preserved, a large temporal infarction was highly possible. Here's M1, temporary clip was placed. Again, this video emphasizes the importance of wide fissure dissection identifying all the vessels within the fissure and making sure that none of them are compromised by deployment of the clip plates. Here you can see a nice area where the neck is dissected away from the temporal trunk. The anatomy is very clear. And we're ready to place the final clip. Here's dissecting behind the neck of the aneurysm to again, make sure they clip plates are easily passed on around the neck without blind dissection through the clip tips. Here's that curve clip easily applied, very precise, preserving all the branches, making sure that clip plate spanned the entire neck aneurysm. Micro-Doppler confirmed patency of all the vessels and occlusion of the aneurysm. Here's the final product. ICG and demonstrates collusion of the aneurysm patency of all the branching vessels. Here is also Floyd Hundred demonstrating symmetric flow within both the M2 branches. I perform this modality because there was some atherosclerosis along the neck of the aneurysm, and I wanted to make sure there is no potential stenosis within the temporal trunk that was not appreciated on the regular ICG video angiogram. Here's the post-operative angiogram demonstrating complete exclusion of the aneurysm without any compromise of the vessels. This patient underwent an MRI for another reason subsequently. And again, you can see there's no evidence of ischemia. This patient made a very nice recovery. Again, this video emphasizes the importance of surgical intuition, wide Sylvian dissection, making sure that all the vessels within the Sylvian fissure are appreciated and none of them are inadvertently affected by the clip plates. Thank you.

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