Partially calcified atherosclerotic aneurysms can present quite a daunting challenge in regards to closure of the clip plates and collapse of aneurysm neck. This is a 48 year old male who presented with an unruptured, partially calcified, 14 millimeter right-sided MCA aneurysm. The extent of calcification on the CT is actually not very impressive. You can see a few punctate areas of calcification. However, these punctuate areas usually signify presence of additional areas of calcification at the neck of the aneurysm. Again, the morphology is quite a standard, relatively large aneurysm. Patient underwent a right front temporal craniotomy. Sylvian fissure was widely dissected. Here you can see the aneurysm of the bifurcation of the MCA. The area of the calcification is readily apparent. I use the tandem clipping technique. First, a straight fenestrated clip followed by a straight clip to close the distal and proximal sections of the neck of the aneurysm respectively. However, these clips were not adequate. You can see intraoperative ICG did initially demonstrate any filling. However fluorescein angiography demonstrated filling of the aneurysm. Placed additional straight clip I suspected the area of the calcification did not allow the second clip to close upon penetration of the aneurysm. The sack continued to fill. I placed another fenestrated clip, another straight clip, repeating their tandem configuration. To my surprise, the aneurysm again continued to fill. Despite these clips, the aneurysm again was filling and therefore quite an impressive number of clips had to be placed to completely exclude this partially calcified atherosclerotic aneurysm. The principle essentially is to assure complete exclusion of the aneurysm while preserving the atrium of the MCA bifurcation. Subsequent postoperative angiogram confirmed the desirable finding of complete collapse of the aneurysm sac without any residual neck. And this patient recovered from his surgery without any complication. Thank you.
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