January 05, 2016
Let's review a nuance of technique for clip ligation of small multi-lobulated MCA aneurysms. This is a 52 year old female who presented with an unruptured small four millimeter right-sided MCA aneurysm. Despite the small size of the aneurysm, since she had previous history of subarachnoid hemorrhage from another aneurysm, treatment was recommended. Here's the morphology aneurysm. Number of lobules are apparent. Because of the small stature of the aneurysm and these lobules, clip ligation can be problematic while completely excluding the aneurysm and preserving the bifurcation. Here's a right side of frontotemporal craniotomy, temporal lobe, frontal lobe, and one temporary clip was used, and here's the multi-lobulated aneurysm, and two trunk coming from the base of the aneurysm. Number of lobules are apparent as expected. I attempted a number of different clips and ultimately settled on using a number of clips lined up parallel to each other and perpendicular to the MCA bifurcation. I find this configuration of clip placement quite effective for excluding very small multi-lobulated aneurysms or very large atherosclerotic aneurysms that may resist simple clipping techniques. The bifurcation has been preserved. Here's flouricine angiography. The aneurysm is completely excluded. The sack is not enhancing. And here's the post operative angiogram, which demonstrated a complete exclusion of the aneurysm without small neck remnant. Thank you.
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