July 29, 2016
Here is another example of a small unruptured MCA aneurysm, with relatively unusual morphology. This is a 52 year-old female who underwent clip ligation of a ruptured contralateral mirror, MCA aneurysm, and incidental right-sided bilobed MCA aneurysm was also identified. She's previously underwent successful clip ligation of the left-sided MCA aneurysm. She was also found to have a questionable blister aneurysm over the ACoA complex. Both aneurysms were exposed via the right-sided frontotemporal craniotomy. Sylvian fissure was split using the inside to outside technique and two branches were found, until the neck of the aneurysm was exposed. Can see the area of the bifurcation, the neck of the aneurysm, very closely related to a perisylvian vein. The neck has to be more thoroughly dissected before the clip blades are deployed across it. Before the clip is placed across the neck of this aneurysm, I further dissected the neck using temporary occlusion of M1. You can see the ball-tipped probe is used to gently dissect around the neck of the aneurysm and allow safe passage of the clip blades. Before deploying the clip on the MCA aneurysm, I wanted to inspect the anterior communicating artery complex for presence of an aneurysm. Here you can see the subfrontal dissection release of the frontal lobe, away from the optic nerve. Here is A1. Following A1 to reach the ACoA complex and inspect the area for presence of a clippable aneurysm. Can see there is a very small blister at the level of the ACoA. However, it is too small to be safely clipped. Further inspection reveals no other clippable vascular abnormality. Here's placement of the permanent clip across the MCA bifurcation aneurysm. Can see the clip has deflated the sack, all the way across the neck, and two branches appear unharmed. Here's the final result. You can see a traumatic dissection keeps the pia surfaces intact, and here's the postoperative angiogram revealing complete exclusion of the MCA aneurysm. Thank you.
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