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  1. Robert W Tarr
  1. Correspondence to Dr R W Tarr, Department of Radiology, University Hospitals Case Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA; robert.tarr{at}uhhospitals.org

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Bows and flows of angel hair

And ice cream castles in the air

And feather canyons every where

I've looked at clouds that way.

But now they only block the sun

They rain and snow on everyone

So many things I would have done

But clouds got in my way.

I've looked at clouds from both sides now

From up and down and still some how

It's cloud illusions I recall

I really don't know clouds at all.

—Joni Mitchell, 1967

One morning my fellow, Justin, wanted to go over a CT angiogram which had been performed overnight on a patient in their mid-50s with suprasellar cistern and right Sylvian fissure hemorrhage. The CT angiogram revealed a smooth walled right internal carotid artery terminus aneurysm which measured 2 mm in diameter. This aneurysm was the only possible source of hemorrhage. Given the patient's age, good Hunt and Hess grade, location of the aneurysm, and wide aneurysm neck, Justin and I both agreed that the best form of treatment for this patient's aneurysm was open surgical clipping. Although some readers might quibble and opine that this patient would be better served with endovascular treatment, for me the decision was rather simple.

But then, I let my mind wander as it …

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