Premature Aneurysmal Rupture without Proximal Control

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This video reviews management of catastrophic intraoperative hemorrhage before aneurysm microdissection. In other words, during the pre-dissection phase. This is a 26 year-old female who presented with sudden onset headache, left-sided weakness, and continued to worsen neurologically upon arrival to the emergency room. An emergent head CT demonstrated a large intracerebral hemorrhage originating in the area of the MCA territory and tracking anteriorly into the frontal lobe. This tracking feature of the hemorrhage will be especially important when estimating the source of hemorrhage during surgery. An emergent CT angiogram also demonstrated a relatively sizable middle cerebral artery aneurysm, closely associated with the proximal branches of the M2 trunk. She subsequently underwent a right fronto-temporal craniotomy. The Sylvian fissure was gently dissected. However, the brain appeared very tense and became even slightly tenser during the dissection. I, therefore, attempted to obtain proximal control as soon as possible by elevating the frontal lobe using the subfrontal trajectory. Again, this is the roof of the orbit, the Sylvian fissure and elevating the frontal lobe to reach the proximal ICA at the level of the skull base. However, elevation of the frontal lobe led to hemodynamic changes around the aneurysm sac causing premature rupture. However, the hemorrhage occurred through the frontal lobe and based on preoperative CT scan, this can be expected. You can see the torrential bleeding occurring through the rupture of the frontal lobe. Obviously, no proximal control is available. Sylvian fissure has not been dissected yet. I divert attention toward the Sylvian fissure and the fissure was quickly dissected. The aneurysm was found by following the flow of the blood. You can see the side of the hemorrhage. Two suction devices were used. I attempted to grab the dome of the aneurysm with the bipolar forceps to control the bleeding as much as possible. However, this maneuver was unsuccessful. Next, I dissected more anteriorly along the fissure interface of torrential bleeding while my assistant was clearing the operative field and used my bipolar forceps to clamp down on the entire MCA complex, so I can achieve some clearance of the operative field to continue further microsurgery. Next, a temporary clip was placed across the entire structure. The M1 was dissected and the temporary clip was advanced onto the M1. The dome of the aneurysm was dissected from the proximal M2 branches, two fenestrated clips were placed across the neck of the aneurysm. The first fenestrated clip was not adequate to close the entire neck. You can see, I removed the temporary clip and further bleeding from the aneurysm is apparent. Here's the second fenestrated clip to close the entire neck of aneurysm. Intraoperative ICG demonstrated patency of the surrounding vessels and occlusion of the aneurysm sac. And you can see the reconstruction of the MCA bifurcation using the straight fenestrated clips. Here's the postoperative CT scan, which demonstrated adequate evacuation of the hematoma and complete exclusion of the aneurysm. This patient recovered very well from her surgery and ultimately returned to work without any significant neurological decline. Thank you.

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