Bipolar Remodeling Aneurysmorrhaphy and Bookend Clip Reconstruction of Complex Middle Cerebral Artery Aneurysm:...

We present the case of a 57-year-old female patient who presented with a large, unruptured complex left middle cerebral artery (MCA) aneurysm with a wide neck and incorporation of M2 vessels. Microsurgical clipping was chosen due to the aneurysm's morphology, location, and rupture risk, with endovascular options deemed less favorable. A left pterional craniotomy was performed, and the aneurysm was reconstructed using bipolar remodeling aneurysmorrhaphy and multiple clip constructs, including the suction pull-through technique (use of the microsuction to manipulate the dome through the clip blades), and bookend clips for dog ear reconstruction. The operative video highlights critical steps such as wide Sylvian fissure splitting, freeing the aneurysm dome from frontal lobe adhesions, achieving proximal and distal control, and reshaping the aneurysm dome under temporary occlusion. Post-clipping indocyanine green, fluorescein, and catheter angiography confirmed excellent bifurcation reconstruction with complete aneurysm obliteration and preserved MCA circulation. Postoperatively, the patient was neurologically intact and was discharged on postoperative day 5. This case underscores the value of tailored clip reconstruction for complex MCA aneurysms using advanced techniques, such as suction pull-through and meticulous bipolar reshaping. Microsurgical clipping remains the first-line approach for large, complex MCA aneurysms, offering high occlusion rates and durability despite inherent risks. The patient consented to the procedure and to the publication of her images. Institutional review board approval was deemed unnecessary due to the retrospective case report nature of this work. This video provides an in-depth review of surgical nuances to optimize outcomes in these challenging cases.