• Yuri Pilipenko and Arevik Abramyan.
• Department of Neurovascular Surgery, N.N. Burdenko National Scientific and Practical Center for Neurosurgery, Moscow, Russia.
• World Neurosurg. 2021 Apr 1; 148: 196-197.

AbstractA 57-year-old man who had previously suffered a transient episode of retrograde amnesia was admitted to the vascular department of the Burdenko Neurosurgical Center. Computed tomography angiography revealed a complex trifurcation aneurysm of the right middle cerebral artery (MCA) bifurcation. There were no clear focal symptoms after the neurologic examination. The patient underwent a right-sided craniotomy to approach the Sylvian fissure and MCA branches. The MCA aneurysm with 2 lobes had been exposed. One of the M2 branches densely adhered to the aneurysm dome. Attempts of the M2 separation along the dome stopped because there was a high risk of injury to the M2, the aneurysm, or both. To cutoff M2 without bleeding from the aneurysm, a curved clip was used, which we called an insulating clip. After this manipulation, it was already possible to try the neck closing with additional clips, however, according to manual sensations, we were not sure that the insulating clip would not shift and there would be no bleeding. The insulating clip interfered with the final clipping and should have been removed. Temporal aneurysmorrhaphy was used to ensure that the surgeon's manipulations were not complicated by bleeding. This also acted as a guarantee that, in the event of bleeding, the rupture would not spread to the neck of the aneurysm. Thus the M2 cutting-off with an insulating clip and temporal aneurysmorrhaphy were options that allowed for adequate final clipping. There were no intraoperative or postoperative complications. The patient remained neurologically intact and was discharged 7 days after surgery (Figure 1).Copyright © 2021 Elsevier Inc. All rights reserved.

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