Aneurysm Dome Excision and Picket Fence Clip Reconstruction of a Previously Coiled Recurrent Giant Middle Cerebral Artery Aneurysm: Technical Nuances.

This video case illustrates key surgical steps required in safe management of a giant recurrent previously coiled middle cerebral artery (MCA) aneurysm (Video 1). The patient described in this case was a 68-year-old man who presented with sudden-onset severe headache and dizziness. The patient had a history of a prior coil embolization of a 12-mm left middle cerebral artery aneurysm at an outside hospital. Imaging demonstrated recurrence now of a giant left middle cerebral artery aneurysm with coil compaction and left temporal lobe edema. Magnetic resonance imaging further demonstrated thrombus in the aneurysm and aneurysm wall enhancement concerning for impending rupture. Given the aneurysm size, imaging features, and mass effect, the aneurysm was treated with microsurgical clipping. This case is valuable to the literature with a clear video case illustration of aneurysm dome excision, aneurysm endarterectomy, and picket fence aneurysm neck reconstruction. Aneurysm dome excision is critical for treatment of giant aneurysms causing mass effect and was only used in this case because thrombus and coil mass did not allow for direct clipping across the neck without compromise of the MCA M2 branch. Hence, this video highlights key technical tenets, such as safe thrombus removal and adequate cleaning of the endoluminal surface and preparedness for bypass in challenging cases.