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Multiple MCA Aneurysms

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Let's review strategies for a clip ligation of patients who present with multiple MCA Aneurysms on the same side. This is a 34 year old female who presented with spontaneous subarachnoid hemorrhage. CT angiogram demonstrated the location of the distal MCA bifurcation aneurysm most likely responsible for the hemorrhage as well as a smaller anterior temporal artery aneurysm. Left frontotemporal craniotomy was completed. Sylvian fissure was noted to be very adherent. In this young patient with evidence of subarachnoid hemorrhage dissection continued along the M2 trunks toward the M1 segment. So that the anterior temporal artery aneurysm can be first excluded. So the most proximal aneurysm should be excluded first. Here's the dissection toward the more proximal aneurysm. Here's the Dome of the aneurysm Careful dissection around the aneurysm neck allowed me to identify and secure proximal control over M1. Here, the dissection around the Dome of the aneurysm until the proximal M1 segment is found. Since proximal control is not yet secured dissection has to proceed very carefully. I attempted to place a straight temporary clip, however this would have interfered with clip ligation of the proximal aneurysm and therefore this temporary clip was interchanged with an angle temporary clip so that the hinge of the temporary clip is out of our working space. Next I attempted straight clip this appeared to cause sub optimal exclusion of the neck and therefore a slightly curved clip was used for complete exclusion of the aneurysm and preservation of the parents vessels. Here's the funnel application of the longer slightly curved clip blades. Next I followed the M1 more distally until the more distal MCA aneurysm is identified. This aneurysm was quite distal and a small portion of the superior temporal gyrus had to be removed in order to identify the neck of aneurysm. Here you can see the neck in two trunks. One of the two trunks is not clearly visible at this time. Further dissection in this area was necessary. Temporary clip was used to mobilize the aneurysm neck and circumferentially isolate the neck. You can see the origin of the other trunk. Straight clip was placed across the neck of this more distal aneurysm. Small amount of Atherosclerosis was present Micro Doppler ultrasound device confirmed patency of the surrounding parent vessels. Here's the final product and a demagnified view of the operative corridor. Post-operative Arteriogram demonstrated complete exclusion of both aneurysms without any interference with a flow within any of the branching arteries. Post-operative CT also excluded any presence of ischemia and this patient recovered from her surgery very nicely. Thank you.

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