Small MCA Aneurysm: Alternative Clipping Strategies

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Here is clip ligation of another small MCA aneurysm and the use of alternative clipping strategies. This is a 48 year old male with small un-ruptured MCA aneurysm. He previously underwent coiling of his ruptured ACoA aneurysm elsewhere because of his severe subarachnoid hemorrhage. This is small left sided MCN aneurysm underwent clip ligation, left frontotemporal craniotomy was completed. This Sylvian fissure was exposed and dissected from the inside to outside technique. Here's the exposure of the Sylvian fissure, relatively an easy fissure to split. Arachnoid bands were carefully dissected using jeweler forceps. The M2 branches were followed toward the MCA bifurcation. Here's the M1, therefore proximal control is secured, and here's the location of aneurysm. Here's the aneurysm sack. There is a perforating vessel draped over the aneurysm. This perforating vessel has to be dissected and preserved, aneurysm as expect is relatively small and very broad base. The neck of the aneurysm is circumferentially dissected. You can see the use of sharp dissection to make sure that the neck is clearly defined. It is important for the neck of aneurysm to be adequately dissected. So clip ligation does not leave a dog ear behind. Here's my attempt to dissect the origin of the perforating vessel. The more medial part of the neck is being dissected. Temporary clip is used on M1 so that the aneurism sack can be more aggressively manipulated. Again, one has to be able to see thoroughly around the neck, so the aneurysm is adequately excluded. Papaverin soaked gel foam is used to relieve spasm on the tiny vessels and maintain their flow. Here's a fenestrated clip, straight one, closing the neck of the aneurysm while preserving the origin of this perforating vessel. I repositioned the clip, so this part of the neck is excluded. Now I can dissect the perforating vessel more efficiently. Now I'm mobilizing neck into the clip, so there's no question about complete exclusion of the aneurysm neck. Patency of the perforating vessel is confirmed using micro Doppler ultrasonography. I'll go ahead and also perform an intraoperative fluorescein angiography as you can see here, confirming the desirable findings. Here's the final result. The operative corridor, a traumatic dissection of the fissure and the post-operative angiogram demonstrated adequate exclusion of the aneurysm, patency of the perforating vessel and the CT scan did not reveal any evidence of ischemia. Thank you.

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