MCA Aneurysm: Intraoperative Rupture

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Let's review techniques for managing intraoperative rupture for clip ligation of small MC aneurysms. This is a 32 year old female, who presented with acute subarachnoid hemorrhage. CT scan identified a sizable temporal hematoma. The aneurysm is pointing laterally and anteriorly and is closely associated with the dura of the sphenoid wing. This close association has been recognized as one of the common risks for intraoperative rupture. This association is more readily visible on the sagittal CT angiogram scan. Patient underwent a right sided front temporal craniotomy. The Sylvian fissure was split. During the initial steps of the operation. Some bleeding was encountered. You can see this structure here that could potentially be the dome of the aneurysm. This bleeding was readily controlled via a piece of absorbent cotton. I redirected my attention more posteriorly, so that the M1 can be identified. The cotton was subsequently removed without any evidence of further bleeding. Here's the aneurysm, here's the M2. I suspect the M1 should be just behind the aneurysm. I gently expose the neck of aneurism. However, encountered further bleeding one more time. This time that the bleeding was again controlled with a piece of absorbent cotton. Since I encountered already two episodes of intraoperative bleeding, I thought it's time to find the M1 as efficiently as possible. Here's looking behind the M2, here's finding the M1. Just pointing away from the neck of the aneurysm. Every tract or blade was used temporarily. You can see a temporary clip was placed across M1. Now I'm looking for the contralateral M2, so that the neck of the aneurysm can be defined more thoroughly. Still, only the neck. I haven't been able to find the contralateral M2 yet. Now I will able to find this vessel. So I'm just about ready to place the permanent clip across the neck. Here's the neck, contralateral M2, ipsilateral M2. Curve clip was used to collapse the neck of the aneurysm, while preserving the origin of both M2's. Here you can see the clip blade is relatively too short. Additional bleeding was encountered from the dome. This time I coagulated the dome of the aneurysm. A longer clip was applied. Small dog ear is apparent, this clip was repositioned. Further inspection revealed adequate exclusion of the neck of the aneurism. The clip lights were perfectly inspected on both sides in the neck. Intraoperative fluorescence angiography revealed exclusion of the aneurysm, patency of the branching vessels. Micro-Doppler ultrasound device confirmed our findings. The aneurysm was penetrated and deflated. And other clip was also applied in a tandem fashion. Since this aneurysm is highly atherosclerotic. Fenestra clip was also used to close the distal neck. I'm satisfied with the construct now. The hematoma was then evacuated to facilitate the recovery of the patient. Here's the final result of the operation. Some brain swelling intention was encountered and the optico-carotid cistern was opened. This led to immediate relaxation of the brain. Postoperative angiogram revealed complete exclusion of the aneurysm without any complicating features. And this patient made an excellent recovery. Thank you.

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