Clipping Surgery for Large ICA Paraclinoid Aneurysms and Pitfalls

For many years, neck clipping of large internal carotid artery paraclinoid aneurysms has been challenging. However, recent technical developments in coil embolization and flow diverters have been associated with great advancements. Indeed, reducing surgical complications related to neck clipping in the era of interventional radiology is essential. The basic techniques include 1) preparation of the cervical carotid artery, 2) cannulation of the carotid artery, 3) craniotomy, 4) sectioning of the falciform ligament, 5) removal of the anterior clinoid process, 6) preparation of the ophthalmic artery, 7) temporary arterial occlusion, and 8) intraoperative angiography or indocyanine green videoangiography. Key points of the surgical techniques include appropriate preparation of the parent artery and selection of the aneurysm clips. Here, some technical details, including the removal of the anterior clinoid process, the separation of the distal dural ring and the transposition of the sphenoparietal sinus, are described to both avoid surgical complications and improve the visual outcome.