MCA aneurysm: overlapping clips technique

Technique and surgical approach by Dr. Javier Ibáñez

In this case uploaded to the online surgery app SurgSchool, the neurosurgeon Dr. Javier Ibanez presents a complex surgical procedure in a 63-year-old patient incidentally diagnosed with an aneurysm in the right middle cerebral artery following a head injury, treated with the overlapping clipping technique. Aneurysms in this area are commonly treated by neurosurgeons due to their accessibility and the difficulty they present in embolizing with endovascular techniques.

Why use the overlapping clips technique?

In this type of aneurysms, wide-based necks make endovascular embolization difficult, so more complex surgical techniques are necessary. The overlapping clip technique, or overlapping clips, is very useful for reconstructing the Sylvian bifurcation and preserving circulation to the distal branches of the middle cerebral artery. This technique allows for precise closure of the aneurysm while maintaining adequate blood flow to the M2 branches, which are crucial for supplying oxygen to the brain.

Step by step of the surgery:

1. Access to the Silvian fissure: The first step in this procedure is to open the Sylvian fissure wide to access the aneurysm. This step is key to minimizing brain retraction and ensuring a smooth surgery.
2. Proximal control and dissection of distal branches: Once the aneurysm is exposed, careful dissection of the distal M2 branches is crucial for preserving blood flow. In this case, the main difficulty lies in the adhesions of the vessels to the dome and base of the aneurysm.
3. Application of clips: With the aneurysm exposed and controlled, two overlapping clips are placed. The first clip covers the anterior half of the dome, while the second, a fenestrated clip, overlaps the first to cover the inferior part of the aneurysm. This technique allows for safe and effective closure, with the goal of reconstructing the Sylvian bifurcation and avoiding complications.
4. Postoperative verification: Once the clips are in place, a Doppler ultrasound and an indocyanine green test are performed to check for proper circulation and ensure the aneurysm is completely closed. These methods verify the effectiveness of the surgery and the absence of ischemic complications.

Advantages of overlapping clips in middle cerebral artery aneurysms:

Dr. Ibáñez emphasizes that this technique is especially useful in aneurysms with complex morphology, such as those affecting the middle cerebral artery. The ability to overlap the clips ensures greater precision and effectiveness in aneurysm closure, minimizing the risk of postoperative complications.

If you are a neurosurgeon and are interested in learning more about advanced clipping techniques for aneurysms, we invite you to register in SurgSchoolOn our platform, you'll have access to more surgeries performed by experts like Dr. Javier Ibáñez and other international leaders in neurosurgery. Don't miss the opportunity to improve your surgical skills and stay up-to-date with the latest techniques!