Bipolar-assisted aneurysm remodeling in microsurgical clipping: safety profile, technical applications, and clinical outcomes

PURPOSE: Bipolar coagulation was historically described as a method for dome or neck remodeling, but concerns about rupture kept it underused. Yet carefully applied, low-power bipolar bursts can safely shrink or stiffen aneurysm walls, improving clip access in select challenging cases. This study aims to systematically evaluate how bipolar coagulation is used during intracranial aneurysm clipping, including its indications, intraoperative roles, and impact on surgical exposure and postoperative outcomes. METHODS: We retrospectively analyzed 50 consecutive patients who underwent microsurgical clipping of intracranial saccular aneurysms in which bipolar coagulation was deliberately employed. High-resolution surgical videos were reviewed to document the timing (pre-clip vs post-clip), target (dome vs neck), and purpose (remodeling, shrinkage, dissection assistance, or repair). Aneurysm morphology, rupture status, clip strategy, and perioperative variables were obtained from operative and radiological records. Patients were monitored clinically and radiographically at standardized intervals up to 24 months. RESULTS: Bipolar techniques were applied for neck remodeling in 31 patients (62%), dome coagulation in 30 patients (60%), post-clip coagulation in 29 patients (58%). Sole bipolar coagulation combined with cotton wrapping was used in 1 patient (2%). No statistically significant differences were observed among groups in preoperative WFNS scores (p = 0.20), discharge WFNS scores (mean 1.38 ± 1.07; p = 0.71), number of clips used (p = 0.56), mortality (p = 0.93), or indication distribution (p = 5.45). Early postoperative imaging demonstrated complete aneurysm obliteration in 48 of 50 patients (96%), while residual aneurysm was detected in 2 patients (4%). Overall mortality during follow-up was 6% (3/50), with no deaths attributable to surgical technique; all deaths were related to vasospasm. CONCLUSION: Selective, low-power bipolar coagulation was used as an adjunct during aneurysm clipping without bipolar-related intraoperative rupture in this series. Its controlled use can enhance visualization, optimize clip positioning, and expand treatment options in anatomically challenging aneurysms.