January 29, 2016
This video describes the basic and fundamental tenets for clip ligation of cerebral aneurysms. This is a 42 year-old male who presented with a six millimeter left sided unruptured MCA aneurysm. You can see that this aneurysm is very typical of MCA aneurysms pointing slightly inferiorly and anteriorly and has a relatively simple morphology for clip ligation. Patient underwent the left frontotemporal craniotomy, Sylvian fissure was widely dissected. You can see the M1, temporary clip was attempted for later use. The dome of the aneurysm was dissected so that the route of this perforating vessel can be determined. Temporary clip was ultimately used, so adequate clip placement can be possible. You can see eventually a longer clip was used across the neck of the aneurysm. This clip did not encompass the entire neck and therefore a second straight fenestrated clip was used to close the distal neck of the aneurysm in a tandem fashion. This manner of clip application is quite effective in order to first close the proximal neck and be able to customize placement of the clip with only attention to the proximal part of the aneurysm and the second clip can primarily focus its attention for closure of the neck. If only one clip is used, this single clip has to adjust to close both edges of the neck. Here's the final product. Both the M2 trunks are well preserved intraoperative ICG angiogram confirms desirable findings. The aneurysm is excluded and all the branching vessels are patent. There is small incidents of false negative results on ICG angiogram. Therefore, if the ICG demonstrates exclusion of the sac, I usually penetrate the sac with a 25 gauge needle to confirm deflation and lack of flow within the sac. Postoperative angiogram demonstrates exclusion of the aneurysm, thank you.
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