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Middle cerebral artery (MCA) aneurysms often have an irregular morphology that might require creative clipping techniques even in the case of small aneurysms. In this video, we illustrate the case of a patient with an incidental but very irregular MCA aneurysm. The presence of 2 separate, asymmetric lobes was dealt with by utilizing the "interlocking" clip technique in which a regular clip is used to obliterate 1 portion of the aneurysm and a fenestrated clip, with the ring of the fenestration circling the body of the first clip, is used to obtain obliteration of the other lobe. This patient also had a contralateral internal carotid artery occlusion, and we discuss the pitfalls of temporary clipping in such a situation.

The present review focuses on the process by which selected pharmacologic agents can be employed in the management of specific problems that arise during surgical procedures, including tumor or trauma with elevated intracranial pressure, previously ruptured aneurysm, and procedures that may require some degree of controlled hypertension, such as carotid endarterectomy or temporary clipping. A balanced view between older established data, newer information, and long-term clinical practice in caring for such patients is presented. The emphasis is on intravenous rather than inhaled agents; issues that involve neuromuscular blockers are not addressed here.

The attachment of a thin silastic sheet combined with the use of Sugita's fenestrated aneurysm clip was developed for the emergency repair of vascular perforation during surgery. The sheet is flexible and tailored in the operating room, corresponds to the vascular curve, and is semitransparent, allowing observation of the area of perforation. The device can be applied under severe bleeding conditions without temporary clipping. It may be useful as an emergency tool for vascular repair in the operating room.