Perfect clipping of atherosclerotic aneurysms can alter flow within the distal branching vessels and lead to post-operative ischemia. Let's review the operative events for a 62-year-old female who presented with an incidental right-sided MC bifurcation aneurysm. You can see the location and configuration of the aneurysm. There is evidence of punctate calcifications within the dome, and potentially near the neck of the aneurysm. Following completion of the right frontotemporal craniotomy, the sylvian fissure was generously exposed. You can see the distal M2 branches. The vessel here is the temporal M2 trunk. A shorter clip was initially placed to spare the temporal trunk and keep its lumen patent. You can see the curve clip. You can see the location of the tip of the clip, just short of the vessel. A longer curve clip was placed in tandem with the first one, so that the inlet into the temporal trunk is preserved. I consider this a rather perfect clipping technique to assure complete exclusion of the neck. Unfortunately, in highly atherosclerotic aneurysms, this perfect clipping technique can compromise the intralumen of the branching vessels. The presence of the atherosclerosis often leads to constriction of the inlet into the lumen of the distal vessels, which may not be apparent upon extraluminal inspection. Here is the deployment of the second clip. Intraoperative ICG shows adequate flow within these vessels without any delay between the frontal or temporal trunks. I was very satisfied with the results of clipping. Post-operative angiogram demonstrates complete exclusion of the aneurysm without any delay in flow within the temporal or frontal trunks. However, the patient unfortunately, suffered from distal temporal trunk ischemia, most likely related to changes in the flow of the branching vessel because of the location of the clip, very close to the inlet of the vessel. Based on this case, and some of my other experiences, I believe that the atherosclerotic aneurysm should not be perfectly clipped, as evidence of atherosclerosis within the lumen of the vessel may lead to significant constriction on the inlet into the branching vessels. Nonetheless, this patient did not suffer from any significant cognitive decline and has made a relatively good recovery. Thank you.
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