Let's discuss pitfalls in clip ligation of atherosclerotic MC aneurysms. This is a 58-year-old female who presented with a one-centimeter, right-sided MC aneurysm. You can see the morphology of the aneurysm, and it's a very distal location at the level of the M1. She subsequently underwent a right-sided frontotemporal craniotomy. You can see the M1 temporal clip placed on this vessel, evidence of significant atherosclerosis at level of the neck of the aneurysm, M2 branches, frontal and temporal. In this situation, it's best to leave a generous atrium behind at the level of the bifurcation. I use the tandem lipping technique. First, a fenestrated clip was used to close the distal neck of the aneurysm, and next a straight clip was used to close the more proximal part of the neck. Further inspection revealed good patency of the bifurcation. Again, extraluminal inspection in this case can underestimate intraluminal stenosis because of the presence of the atherosclerosis. Post operative angiogram demonstrated complete exclusion of aneurysm. This patient awoke from her surgery neurologically intact. However, the CT scan demonstrated questionable hypodensity in the temporal lobe. Interestingly, on the three-month CT scan, this hypodensity was not apparent. Therefore, the initial hypodensity on the CT scan could be related, potentially, to hypoperfusion, related to some compromise of the MCA bifurcation of this hypoperfusion Fortunately, it did not lead to a permanent ischemia and this patient recovered from her surgery effectively. Thank you.
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