January 18, 2016
This video is an excellent demonstration of handling a couple of different intraoperative misadventures during clip ligation of MCA aneurysms. This is a 62 year old female who presented with a 10 millimeter right-sided MCA aneurysms. You can see the irregular morphology of this aneurysm primarily originating around the level of the MCA bifurcation and mostly based over the temporal M2 trunk. A right frontal temporal craniotomy was completed. Sylvian fissure was carefully dissected, and the M2 branches found, and pursued toward the MCA bifurcation. You can see the inside to outside technique for dissecting the fissure. Obviously, in cases, the fissure is quite adherent. Patience and sharp dissection is most appropriate. The M1 could not be easily found despite ample dissection around the M2 branches. Here's the dome with the aneurysm adherent to the sub frontal area. dissection was necessary to mobilize the dome of the aneurysm while avoiding premature rupture. You can see the dome is being mobilized, so I can go around and over the pole of the dome to find the M1, that is apparent at the tip of my arrow. A longer segment of the M1 is exposed, so a temporal clip can be implanted. Here again is the dome of the aneurysm. And a temporal clip was attempted, a curved one. You can see one of the perforating vessels. One of my fellows the clip too aggressively, and you can see the bleeding from one of the perforating vessels. In this situations, it's best to avoid aggressive coagulation, and use a piece of cotton soaked in thrombin, and gently tampon out the bleeding with the hope that the lumen of the perforator can be potentially saved. Here's the cotton that is left in place. Here's the M1, just proximal to the aneurysm dome. The injured perforating vessel is again covered with this piece of cotton. A shorter temporal clip is applied and the aneurysm is circumferentially dissected at the level of its neck. Here you can see the M1, the M2. Here's the dome of the aneurysm. One of the M2s. Now, the other M2 has to be identified. Again, the dome of the aneurysm had to be mobilized further. I coagulated part of the dome to mobilize the aneurysm out of my way to find the other M2. Unfortunately, I did not estimate the exact location of the other M2, and inadvertently injured the wall of that M2 during the sharp dissection that you will witness in a moment. Again, you can see the M2 here, the dome of the aneurysm, the neck, as I continue to mobilize the dome just as you can see the other M2 was unfortunately injured. There's a tear in the wall of the vessel. Similarly a piece of cotton was used in this case. Primary repair of the vessel was not deemed very safe based on its location. Again, temporary occlusion of M1 is still in effect. You can see this small tear at the proximal M2 trunk. The dome is reduced. Aneurysmorrhaphy is conducted, so that a permanent clip can be efficiently placed, so that the extent of tear and injury to the vessel and patency can be examined after the permanent clip is deployed, and the temporary clip is removed. Here you can see the small tear in the proximal M2 trunk. We're just about ready to deploy the permanent clip. I have wrapped the area of the tear at M2 level using a piece of cotton. A curved clip is applied and held in place using the permanent angled, or curved clip. Good reconstruction is apparent. The M2 branches do not appear compromised. The bifurcation is well reconstructed. The cotton is maintained in its place. Temporal clip is removed. Additional bleeding is not encountered. Micro-Doppler ultrasonography confirms good flow in the branching vessels, including the injured M2, papaverine soaked. Gel foam is used to bathe the vessels and relieve their spasms. Intraoperative fluorescence and geography demonstrates good patency of the branching vessels. Here are the fluorescence findings using fluorescein. Good patency of the injured branch. No feeling of the aneurysm. Here's the final result, the magnified view. EVD was removed. Postoperative angiogram demonstrates exclusion of the aneurysm without any complicating feature, or compromise of the injured lumen vessel. And this patient recovered from her surgery without any ischemic events. Thank you.
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