Here's another example of a ruptured small MCA aneurysm and intraoperative findings. This is a 52 year-old female with relatively small amount of subarachnoid hemorrhage and a left sided MCA bifurcation aneurysm. She underwent a left frontotemporal craniotomy. You can see the, thin amount of subarachnoid hemorrhage. In this case, the Sylvian fissure was dissected first by opening the fixed superficial Sylvian arachnoid bands followed by the inside to outside technique to split the fissure widely. Here you can see the inside to outside technique. The M2 branches were identified early and followed towards the neck aneurysm. As you can see the fissure quite adherent in the presence of subarachnoids hemorrhage. Sharp dissection is usually the most atraumatic method to dissect the fissure here. Here again, you can see the identification of the distal M2 branches and following them towards the neck of aneurism. These arteries are quite effective roadmaps for reaching the aneurysm neck. The arachnoidal bands over this sphenoidal segment of the fissure are also dissected. Now you can see their vasculature over the MC territory is more evident. Sharp dissection is used, a temporary clip was placed on M1, however, you can see the angle is not appropriate, and therefore a curve temporary clip was ultimately utilized so that there is ample amount of space to work with aneurysm neck. So here's distal M1, occluded temporarily by the temporary clip. Here's the aneurysm sac relatively broad based. Dome is adhering to the surrounding structures, interfering with exposure of the neck and identification of the temporal M2. Following sharp dissection, the neck was circumferentially isolated, and a curved clip was placed across the neck of the aneurysm while preserving genus atrium for the MCA bifurcation. Subsequently, the temporary clip was removed. Here's fluorescein angiography revealing the fact that the muscles are , the aneurism is occluded. Similar findings are evident on ICG angiogram. Papaverine-soaked gelfoam was used to relieve the spasm over the surrounding areas. And the postoperative angiogram revealed complete exclusion of the aneurysm without any complicating feature. Thank you.
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