The cotton clipping technique can be quite a life saving maneuver, for repair of a neck tear during clip ligation of cerebral aneurysms. This is a 56 year old female who presented with a ruptured right sided seven millimeter posterior communicating artery aneurysm. On preoperative imaging. You can see the location of the aneurysm which is typical of the PCoA aneurysm. In this case the aneurysm was pointing relatively straight, posteriorly. A right sided frontotemporal craniotomy was completed the anterior limb of the Sylvian fissure was dissected and a portion of the Klein art process was removed into intradural. You can see the neck of the aneurysm. A straight clip was placed across the neck of the aneurysm as you can see here, and as the temporary clip across the ICA was removed. The permanent clip across the neck of the aneurysm was unfortunately displaced leading to a tear, at the neck of the aneurysm. I placed a piece of cotton at the region of the neck of the aneurysm. And reapplied the clip, you can see the bleeding in the region of the neck. And reapply the permanent clip over their cotton. You can see how the cotton prevented further bleeding right at the location of a tear. The curve clip, kept the cotton at the site of bleeding, control the bleeding. This clipped was further moved closer to the neck of aneurysm to avoid a dog here. Here you can see the final construct. The pea cam appeared to be patent, or at least it's perforator. The post-operative sylvian tear gram demonstrates near a complete exclusion of the aneurysm within a small amount of residual neck that has remained stable during the past two years of imaging. Thank you
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