Partially Thrombosed Distal MCA Aneurysm

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This video reviews management of distal fusiform MC aneurysms. This is the case of a 62-year-old female with a severe headache following a fall. She was diagnosed with this fusiform distal MC aneurysm. Most likely unruptured. Due to the morphology of the aneurysm, she underwent treatment. A right frontotemporal craniotomy was completed. This is the posterior aspect of the superior temporal gyrus Navigation using a CTA was employed. Small corticotomy within the nondominant posterior superior temporal gyrus was completed. Direct cortical stimulation was used for continuous monitoring of motor evoked potentials, since trapping of the aneurism was very likely, which will lead to sacrifice of one of the M2 branches. Here's the aneurysm mostly thrombosed. You can see the proximal MCA vessel leading to the aneurysm through the posterior aspect of the Sylvian fissure. The aneurysm was circumferentially isolated. Here's mobilization of the aneurysm so that I can find the outgoing vessel leaving the aneurysm neck. Here's the incoming vessel. This vessel leads into the aneurysm. Further dissection revealed the more distal segment of the vessel affected by the aneurysm. This appeared to be an emphasized vessel, not necessarily associated directly with the aneurysm sac. Here's the exiting branch of the MCA. The neck of aneurysm does not appear to be reconstructible, preserving the lumen of this MCA branch affected by the aneurysm. I placed two temporary clips, both proximal and distal to the aneurysm after the aneurysm was reduced using bipolar coagulation. There's a temporary clip proximal to the aneurysm. Temporary clip was placed distal to the aneurysm, and intra-operative ICG angiogram was completed, demonstrating retrograde flow toward the aneurysm, providing good information that sacrifice of this MCA segment is most likely tolerable. I opened the aneurysm sac and attempted to remove some of the intrasacular thrombus. However, I quickly found out that this maneuver is not going to be beneficial in improving my chances of preserving the lumen of the affected vessel. Therefore, temporary clips were replaced with permanent clips, and aneurysmal trapping was accomplished. Here's removal of a temporary clip. Replacement of the clip with permanent clips. A postoperative CT excluded subschemia. Postoperative angiogram demonstrated retrograde flow toward the point of exclusion of the aneurysm, and that segment of the MCA. And this patient did not suffer from any untoward effect after her operation. Thank you.

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