Small MCA Aneurysm: Calcification at the Neck

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Let's discuss some of the challenges we face in clip ligation of small MCA Aneurysms, more specifically, presence of calcification or atherosclerosis at the neck of the aneurysm. This is a 61 year-old female who presented with acute subarachnoid hemorrhage. CT angiogram demonstrated a small aneurysm around the area of the MCA bifurcation. Patient underwent a right-sided front and temporal craniotomy, unfortunately, this patient suffered from significant amount of subarachnoid hemorrhage upon rupture of her aneurysm. The M2 branches were identified within the Sylvian fissure, and I continued more proximal dissection toward the bifurcation, located here. This aneurysm was somewhat more based toward the M2 trunk on the temporal side, before further dissection is conducted. Proximal control was secured at the area of the distal M1. Temporary clip was used across the distal M1, so more efficient maneuvers can be conducted next for exposure of the aneurysm of neck. Here's most likely the proximal neck of the aneurysm. Sharp dissection continues, here you can see the more defined portion of the neck, proximally. Distal neck is also apparent. I'll continue dissection behind the aneurysm, so that the clip light can be passed effectively and not blindly. Here is some atherosclerosis at the neck of the aneurysm. I'll go ahead and try an angled clip. Initially, it looked pretty good. However, upon examination of the M2 trunk using the Doppler ultrasonography device, there was no evidence of flow within the temporal M2. The front of M2 remain patent. Most likely the clip is compromising the lumen of the vessel at the area of the atherosclerosis. Apparent soap gel foam was used to relieve any spasm in the area. The clip was obviously removed and a straight clip was used. This time the blades were deployed slightly more distal along the neck of the aneurysm. This is an important concept that during the placement of the initial clip, external examination of the lumen revealed no evidence of stenosis, but because of presence of atherosclerosis, the clip most likely led to stenosis of the vessel, intraluminally, because again, the increased thickness of the vessel due to atherosclerosis. Here is the distal tip of the clip plate. It's across the entire neck of the aneurysm. Small blister across the aneurysm was coagulated. The clip was repositioned to assure the lumen is not compromised. Here is another repositioning maneuver. I'm staying just as far as I can from the lumen of the vessel. This time, the vessel is patent. ICG angiography confirms patency of the ranching vessels, and complete exclusion of the aneurysm. Here's another examination of our clip construct. I'm pretty satisfied with the final product. Here again the area of the atherosclerosis, that gave us some challenge. Postoperative angiogram revealed complete exclusion of the aneurism and the CT scan revealed no evidence of Ischemia, and this patient made an excellent recovery. Thank you.

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