1032. Bipolar cauterization for the surgical treatment of complex Middle Cerebral Artery aneurysm: surgical technique description

Authors: Luke Alan Mugge; Andrew Carras; Azedine Medhkour (Perrysburg, OH)

Introduction: Middle cerebral artery (MCA) aneurysms are common neurovascular conditions that require either endovascular coiling or open microsurgical technique. MCA aneurysms are often complex, occurring at the bifurcation or trifurcation. Methods: We describe our surgical technique employed to gain hemodynamic control and the surgical clipping of the aneurysm. Patient charts and operative notes were reviewed as part of the preparation. Results: A large MCA aneurysm was discovered on computerized tomographic angiography (CTA). Cerebral angiogram disclosed multiple vessels arising from the aneurysms as well as a wide neck presence, negating the possibility of endovascular intervention. After positioning the patient, an intra-operative angiogram was performed to allow for the exact visualization of the aneurysms prior to surgery. Slack brain was achieved by appropriate head positioning, mannitol, and through maintenance of a CO2 between 33-35. After visualization of the carotid and the MCA trunk, temporary clipping was used prior to the manipulation of the aneurysm and its surroundings. The aneurysm was found to be embedded and covered by multiple adherent veins as well as arterial branches that were part of the sack. Four large vessels were found to originate from the sack itself. After exposure, it was determined that standard clips could not expand enough to fit across the aneurysm’s body. Alternatively, bipolar cauterization was applied on all sides and successfully reduced the size of the aneurysm by 50%. The bipolar current was reducing to 20mv and the tips are maintained wet by continuous small irrigation. This allowed for application of two right angle clips and led to the reconstruction of the MCA at its bifurcation/trifurcation. Conclusion: We have found this approach to be safe as long as the dissection is meticulous and the bipolar cauterization applied in a judicious manor, avoiding premature rupture and utilizing temporary clipping as needed.