Clip ligation of blister aneurysms can be somewhat challenging because of the very small stature of these aneurysms, non amenable to deployment of a clip effectively. Let's go ahead and review this case example of a 51 year-old female with a previous history of subarachnoid hemorrhage from another aneurysm. She was also diagnosed with a small MCA bifurcation aneurysm on the left side. Retrospectively there is a small blister aneurysm on the M2 branch. However, I did not recognize this pre-operatively. Patient underwent a left front temporal craniotomy sylvian fissure. Hydrodissection may be used to separate the lobes and expand the fissure in this case. Next, arachnoidal dissection continued until the M1 and M2 branches are under direct vision. Here you can see the aneurysm. Further inspection around the neck revealed this very small blister aneurysm off of the M2 trunk. You'll be able to appreciate its anatomy more now. Here you can see they're very small stature blister aneurism off of the proximal M2. First, the large aneurysm was addressed. Its neck was circumferentially isolated and a straight clip was applied for its complete ligation. The challenge with clip ligation of blister aneurysms is that the clip plates, no matter how small or if their mini clips are used or most likely too thick to close the aneurysm effectively without sliding off of the aneurysm dome. I like to use a piece of cotton to wrap the aneurysm at the level of its neck. And next apply a clip. In this case, this method was not effective. The curve clip continued to slide off of the aneurysm. Therefore, I tried a straight clip. Here it is, placement of this straight clip under temporary occlusion of M1. So I'm able to manipulate the normal wall of the M2 more readily under regional circulatory arrest. Here you can see the piece of cotton creates more surface for the clip plates to embrace the neck of the aneurism and minimize their risk of delayed displacement of the clip plates. This patient recovered from her surgery effectively and the post-operative CT scan was unremarkable. Thank you.
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