Sylvian Fissure Dissection and MCA Aneurysm

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Let's discuss methods for dissection of this Sylvian fissure. This is a 41 year-old female who presented with an unruptured eight millimeter MCA aneurysm. Here's the morphology of the aneurysm and the origin of the M2 branches. Left frontotemporal craniotomy was completed. I first use a round arachnoid knife to dissect the superficial arachnoid bands, which are often quite thick. Next, the spreading action of the bipolar forceps, allowing entry into the Sylvian cisterns. Jeweler forceps also gently tear and have also fixed superficial bands while preserving the encasing thin superficial veins. This method is quite efficient. Next, the inside to outside technique, allows further opening of the Sylvian fissure. You can see that I start from the inside of the fissure and then continue dissection superficially. The presence of the vessels provide a nice roadmap in order to continue dissection more superficially where the interdigitating opercula can be quite difficult to dissect. Sharp dissection is preferred. The M1 is identified. One may use a temporary clip if necessary to further enhance the dissection of the aneurysm. Here's the location of the aneurysm, relatively broad based. Presence of atherosclerosis at the origin of M2's. The neck is circumferentially dissected. Here you can see looking around the neck of the aneurysm so that the blades are placed effectively without any resistance. In this case, an angled clip appeared to be a nice choice. I prefer to clip the aneurysm as much parallel to the axis of the M2 trunks. The clip is gently closed. The aneurysm may be manipulated so that appropriate clip deployment is possible. The blades are all the way across the neck of the aneurysm. confirms complete exclusion of the aneurysm without any complicating features. And here's a postoperative CT scan confirming lack of any ischemia. And the postoperative angiogram confirmed complete exclusion of the aneurysm. Thank you.

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