Multiple MCA Aneurysms

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This case example contains several good teaching points. This is a young patient, a 32 year-old female who presented with subarachnoid hemorrhage and was noted to harbor a large right-sided broad base ophthalmic artery aneurysm. The initial CTA did not demonstrate any evidence of also right-sided MC bifurcation aneurysms. Patient subsequently underwent a right sided frontotemporal craniotomy, for a clip ligation of this large ophthalmic artery aneurysm. The postoperative angiogram, as you can see here revealed good occlusion of the aneurysm. A small amount of neck had to be left behind to protect the origin of the ophthalmic artery. However, postoperative angiogram also demonstrated the presence of two small aneurysms on the right side or ipsilateral MCA tree, one along the anterior temporal artery origin, and one at the level of the MCA bifurcation. Both aneurysms were very small, and were unfortunately missed on the initial preoperative assessment. They could have been clipped during the same operation as the right sided of ophthalmic artery aneurysm. Subsequently the patient underwent a re-operation 10 days after her initial operation for the ophthalmic artery aneurism. The Sylvian fissure was widely dissected. Here is the clip from the first operation across the ophthalmic artery aneurism. The entire segment of the M1 and the MCA bifurcation were exposed. You can see this more proximal aneurysm, further dissection at the iliac bifurcation revealed the MCA bifurcation aneurysm. Here's the very small anterior temporal artery aneurysm, more de-magnified view of our operative corridor. Again, this is the small anterior temporal artery aneurysm. We'll go ahead and also expose the MCA bifurcation aneurysm as demonstrated here. The neck is carefully dissected. The proximal aneurysm at the level of interior temporal artery is clipped ligated first. Here's the more proximal segment of M1 for proximal vascular control, temporary clip was placed so that this very small aneurysm can be adequately clip ligated. And also the distal aneurysm can be more effectively dissected across the circumference of its neck. Here's the use of curve clip across the neck of the anterior temporal artery aneurysm. In a very small aneurysm, often difficult to catch the entire aneurysm within the clip lights. And now a straight clip is placed across the neck of the aneurysm at the level of the MCA bifurcation. Here's the final result. Temporary clip was removed, further inspection reveals exclusion of the anterior temporal artery, as well as the MCA bifurcation aneurysms. Fluorescein angiography confirms the desirable findings occlusion of aneurysm. Here's a more de-magnified view of our operative corridor and the post operative angiogram confirmed complete exclusion of the aneurism at the level of the MCA tree without having the self schema on the post operative CT scan. Therefore, one of the good learning points from this video is the fact that the CT angiogram can overlook the presence of very small aneurysms, specially at the area of the MCA, where there is a lot of vascular traffic and a lot of vessels present. Again, hiding very small aneurysms. If this patient's MCA aneurysms had been diagnosed during the initial operation for the ophthalmic artery aneurysm, they could have been managed during the same operative session. Thank you.

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