This video reviews techniques and tenets for Microsurgical Clip Ligation of classic MCA Aneurysms, and also describes some of the challenges associated with intraoperative fluorescence. This is a 52-year-old female who presented with an approximately eight millimeter right-sided MCA aneurysm, and due to her young age and broad base of the aneurysm, underwent microsurgical clip ligation. On this 3D reconstruction cerebral catheter angiogram, you can see the morphology of the aneurysm and the associated small blister aneurysm, that most likely increases the risk of rupture, from this aneurysm. You can also see a higher magnified view of the aneurysm neck, in relation to the M2 branches. This patient looks likely underwent a right frontotemporal craniotomy and resection of the lateral sphenoid wing. The dura was opened in a curvilinear fashion and the Sylvian fissure was exposed. The fissure was dissected in the inside to outside fashion, as you can see. The anterior aspect of the fissure was also open generously. So a retraction can be used via gravity to dissect, the fissure further. Here is placement of a temporary clip over the M1. Here is the neck of aneurysm, that is being dissected across the frontal branch. The dome of the aneurysm is decompressed. Here is the temporal branch, that is evident and the location of the neck relationship to this segment. The dissection is carried out circumferentially around the neck of the aneurysm. You can see a perforator attached to the dome of the aneurysm that will be preserved. A curve clip is ideal for clip ligation of the aneurysm. Here's that curve clip, it's placed across the neck, perpendicular to M1. Obviously the tips of the clip have to preserve the temporal branch. No fixer tractors are used due to generous dissection, of the Sylvian fissure. Falling exclusion of the aneurysm intraoperative fluorescence both ICG and fluorescein, confirm complete exclusion of the aneurysm without any complicating features. The dome of the aneurysm was penetrated. As you can see, there's still some filling of aneurysm despite, our remarkable fluorescence results. An additional curve clip was applied to completely exclude the aneurysm. This is the final result. As you can see, avoidance of fixed retraction, avoids any cortical injury to their frontal, temporal or percolate. An important learning session about this video and case is that even though fluorescence's negative, penetration of the dome is the most reliable method, to confirm complete exclusion of the aneurysm sac. Postoperative angiography reveals complete exclusion of the aneurysm and the postoperative CT scan did not reveal any evidence of ischemia. Thank you for your attention.
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