Background and Study Aims Complete microsurgical clip occlusion of an aneurysm is one of the most important challenges in cerebrovascular surgery. Incorrect position of clip blades as well as intraoperative aneurysm rupture can expose the patient to serious complications such as rebleeding in case of aneurysm remnant and cerebral ischemia in case of occlusion of branching arteries or perforators. The aim of this study was to identify independent predictors of surgery-derived complications (aneurysm remnant and brain ischemia) as well as intraoperative aneurysm rupture in an institutional series of patients. Material and Methods This is a single-institution, retrospective cohort study including 147 patients with 162 aneurysms that were selected for microsurgical clipping due to intracranial aneurysm in a 5-year period. Bivariate and multivariate analyses were performed to identify independent predictors among demographic, clinical, and radiographic factors. Results Increasing aneurysm size with a cutoff value at 9 mm (p = 0.009; odds ratio [OR]: 0.644) and irregular dome shape (p = 0.003; OR: 4.242) were independently associated with brain ischemia and aneurysm remnants that occurred in 13.6 and 17.3% of patients in our group, respectively. Intraoperative rupture was encountered in 27% of patients and its predictors were patient's age (p = 0.002; OR: 1.073) and increasing aneurysm size with a cutoff value at 7 mm (p = 0.003; OR: 1.205). Conclusion Aneurysm size, patient's age, and irregular dome shape were the most important risk factors of aneurysm remnant, brain ischemia, and intraoperative aneurysm rupture in our series of patients. We were not able to define a cutoff value for patient's age, but our results showed that with increasing age the risk of intraoperative aneurysm rupture increased.

<b><i>Introduction:</i></b> We present a very rare case of ruptured superior hypophyseal artery (SHA) aneurysm that presented as an acute subdural hematoma (SDH) discussing its initial presentation, diagnosis, and treatment modalities. To our knowledge it is one of very few if any cases of a ruptured aneurysm in infants regarding that specific vascular location. <b><i>Case Report:</i></b> A 5-month-old boy was referred to our department due to acute SDH over the right cerebral hemisphere without significant mass effect nor hydrocephalus. Further evaluation revealed a right internal carotid artery (ICA) aneurysm arising from the SHA segment. Microsurgical clip ligation using a fenestrated, angled clip was performed with simultaneous subdural clot removal and proximal control of the ICA dissected in the neck. Our patient made an excellent recovery without any complicating features. <b><i>Conclusion:</i></b> Surgical management seems to be a better option in this subgroup of patients given the long life expectancy and durability of microsurgical clip ligation. We believe that our brief case report would add some insight into the management of this rare subgroup of patients, leading to better decision-making and outcome.

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Introduction. The aim of this study was to evaluate whether Anterior Communicating Artery (AComA) complex rotation in axial plane may influence the ease of surgical exploration in this region and safety of clip positioning when left vs right-sided approach is compared. Materials and methods. This is a retrospective study based on analysis of patients operated due to AComA aneurysm, both ruptured and unruptured. AComA complex position in relation to coronal plane was evaluated using 3D-CTA VR reconstructions. Next, comparison between surgical approach from the side where A1-A2 junction (angle) was located anterior and posterior to coronal plane was performed in relation to surgical difficulties and intra- and postoperative complications. Results. Subgroup statistical analysis revealed that there is a strong and statistically significant correlation between AComA complex rotation and surgical difficulties expressed by the need of repeated temporary clip application and brain transgression. When anterior vs posterior angle side approach was compared in relation to surgical difficulties and complications, there was a statistically significant difference with strong correlation (p <0,05) in favour of posterior angle side approach. Interestingly, in 72,7% and 45,5% of patients that were operated from the side where A1-A2 junction was located posterior to coronal plane, the approach was performed form the side of a non-dominant A1 and aneurysm dome projection side, respectively. Conclusions. Despite its limitations, our results suggest that microsurgical clipping strategy of AComA aneurysms should at least include AComA complex rotation in axial plane, besides well acknowledged factors, when deciding from which side these lesions will be approached.