October 28, 2019
This is another video describing the transcortical approach through the superior temporal gyrus to evacuate the hematoma and clip a MCA aneurysm, which primarily presented with intracerebral hemorrhage. This is a 63 year old female who presented with intracerebral hemorrhage. You can see the CT scan here, relatively sizable hemorrhage. CT angiogram coronal view demonstrates the location of the aneurysm and the dome directly pointing at the hematoma. Here also, you can see the 3D reconstruction of a CTA showing a relatively sausage shaped MCA aneurysm. I think the operative strategy is to evacuate the hematoma to achieve brain decompression, and then stay close to the M1. Follow the M1 within the Sylvian fissure and then move distally. One has to avoid the dome and directly manipulating it early on surgery before securing vascular control. Here's a right side of front temporal craniotomy, temporal lobe, frontal lobe, Sylvian fissure, sphenoid wing. I went ahead and created corticotomy at the area of the hemorrhage. As you can see here in through the hemorrhage, left some hemorrhage over the dome, and then find the M1 at the tip of my arrow within the fissure. Now that the M1 is identified, I can go ahead and move distally. Here you can see the bifurcation, small amount of brain over the aneurysm. Can see there, bifurcation area, the two trunks. Went ahead and use a temporary clip and continue to dissect the aneurysm, as you can see here, here is the dome. This allows a nice dissection around the nick of aneurism. Here is the aneurism, the M2 branches, the nick of the aneurysm coagulating the point of hemorrhage and rupture. Again, please note the temporary clip on M1. Can see the aneurysm is circumferential dissected so I can place the clip and make sure the aneurysm is thoroughly excluded. Here's the mobilization of aneurism outside the axilla of the M2s. I wanna make sure I don't leave a dog ear. Now I use a curve clip. Since the aneurysm is well dissected, clip placement is very easy. Here is the ICG demonstrating complete exclusion of the aneurysm and patency of the branching vessels. Here's the demagnified view and here's the postoperative angiogram demonstrating complete exclusion of the aneurysm with patency of all the vessels. And this patient did extremely well after surgery. Thank you.
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