This video describes techniques for a clip ligation of multiple or two aneurysms around the area of the M1 bifurcation. This is a 42 year old male, who presented with two aneurysms around the MCA bifurcation. On CT Angiogram, M1 is apparent. There is one small aneurysm at the level of M1 bifurcation. And there's another small aneurysm at the level of the M2 bifurcation. You can see the projection of these two aneurysms. And Right Frontotemporal Craniotomy was done. Sylvian Fissure was widely exposed. A round arachnoid knife was used to start the arachnoidal incision jeweler forceps. It expanded this superficial incision and micro scissors, as well as the spreading action of the bipolar forceps widely split the fissure. Here, you can see the anatomy of the M1 bifurcation and M2 trunks. Here's the M1 vessel located. Here is the M1 bifurcation, the M2 trunk frontal, and M2 trunk temporalis hidden underneath the more proximal in aneurysm. I placed a temporary clip on M1, under burst suppression to deflate these aneurysms and specifically the more proximal one. So that the origin of the temporal M2 trunk can be more established. You can see the temporal M2 trunk. I cannot see around the neck of the aneurysm well. So a temporary clip was deployed on M1. Now, the aneurysm is more deflated. A tentative clip was placed, so I can expose the proximal neck of the aneurysm more adequately. You can now see the origin of the M2 trunk. This clip is slightly short. Therefore, the clip will be advanced. That aneurysm is completely excluded now. Next, the M2 bifurcation aneurysm is being carefully defined. And two clips were used to completely exclude this aneurysm. Postoperative 3D Angiogram demonstrates complete exclusion of both aneurysms. An important learning point from this video, is the importance of first clip ligating the proximal aneurysm before tackling the distal aneurysm. If this order is reversed, the distal clips can potentially interfere with the working angles necessary to deploy the clip under proximal aneurysm. Thank you.
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