Cotton-Clipping Technique to Repair Intraoperative Aneurysm Neck Tear: A Technical Note BACKGROUND: Intraoperative rupture of an intracranial aneurysm is a potentially devastating but avoidable and manageable complication of aneurysm surgery. OBJECTIVE: To describe a surgical technique that the authors have used successfully to repair a tear at the neck of an intracranial aneurysm, as well as alternative options for managing this intraoperative complication. METHODS: The tear on the neck of the aneurysm is covered with a small piece of free cotton and held in place with a suction device to clear the field of blood. The cotton is then clipped onto the tear with an aneurysm clip, using the cotton as a bolster to obliterate the tear. The cotton increases the surface area, allowing the clip to be placed more distally on the neck to preserve patency of the parent artery. Case examples are used to illustrate the technique. RESULTS: Both authors independently have used this technique on several occasions to successfully repair tears at the neck of an aneurysm. CONCLUSION: Intraoperative rupture of an intracranial aneurysm is a potentially dev- astating complication, particularly if a tear occurs at the neck. This simple yet effective method has been very useful in repairing a partial avulsion or tear of the neck of an aneurysm. KEY WORDS: Aneurysm, Aneurysm clipping, Cerebrovascular surgery, Subarachnoid hemorrhage Neurosurgery 68[ONS Suppl 2]:ons294–ons299, 2011 DOI: 10.1227/NEU.0b013e31821343c6 T he intraoperative rupture of an intracranial aneurysm is a potentially devastating but preventable and manageable complication of aneurysm surgery. 1-9 Proximal arterial control, temporary clipping, and sharp dissection may reduce the risk of intraoperative aneurysm rup- ture. 1-3 An intraoperative rupture that occurs after full exposure of the aneurysm usually can be managed without ill consequences to the patient. 1,3-6,9 Intraoperative ruptures most often involve the dome of the aneurysm. In such cases, an appropriately applied clip will both halt the hemorrhage and repair the aneurysm. An intra- operative rupture or tear of the neck of the an- eurysm, however, is a devastating misadventure. Use of an aneurysm clip to occlude the tear almost invariably narrows, and often occludes, the parent artery, potentially resulting in ischemic insult. We report a technique for managing an in- traoperative tear of an aneurysm neck by using cotton as a bolster applied with an aneurysm clip or clips to occlude otherwise irreparable aneu- rysm neck tears while maintaining patency of the parent artery. This technique has been used independently by both authors and was reported as a single case report by the senior author (RFS) in 2003. 10 Over the years, this technique has been used successfully in a number of cases, and we believe that it is important to reintroduce the Daniel L. Barrow, MD*‡ Robert F. Spetzler, MD‡ *Department of Neurosurgery Emory University School of Medicine, Atlanta, Georgia; ‡Division of Neurological Sur- gery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona Correspondence: Daniel L. Barrow, MD, Department of Neurosurgery, 1365-B Clifton Rd., N.E., Atlanta, GA 30322. E-mail: daniel.barrow@emoryhealthcare.org Received, July 6, 2010. Accepted, October 2, 2010. Copyright ª 2011 by the Congress of Neurological Surgeons WHAT IS THIS BOX? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code above links to Supplemental Digital Content from this article. ABBREVIATIONS: EC, extracranial; IC, intracranial; ICA, internal carotid artery; ICG, indocyanine green; MCA, middle cerebral artery; PICA, posterior inferior cerebellar artery; SAH, subarachnoid hemorrhage Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.neurosurgery-online.com). ons294 | VOLUME 68 | OPERATIVE NEUROSURGERY 2 | JUNE 2011 www.neurosurgery-online.com CEREBROVASCULAR Operative Nuances Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.