Intradural clinoidectomy for clipping left paraclinoid aneurysm: Three-dimensional operative video

Paraclinoid aneurysms represent a true microsurgical challenge for resolution [1,2] due to the proximity with neurovascular structures of the skull base [3–5]. We present a case: a 42-year-old woman with headache, detecting left paraclinoid aneurysm in angiography. A left pterional approach plus exposure of the internal carotid at the cervical level were performed. Also, an arciform durotomy with the opening of the sylvian fissure to the carotid cistern, were done. The anterior clinoid process was exposed, observing the aneurysm originating from the clinoid segment of the carotid artery, being impossible the clipping without anterior clinoidectomy [4,5]. The dura was cut medially from the optic canal to the clinoid process. Drilling was performed at the base of the clinoid process to expose the distal carotid dural ring.The carotid was released in the clinoid segment through the section of the distal dural ring to mobilize it. After identifying the distal and proximal neck of the aneurysm, the reconstruction was started by placing a 90 degrees clip in the anteroposterior direction; then, a second clip in the posteroanterior direction and puncturing the aneurysm, showing that the aneurysmal flow is present. A third and fourth clip, were placed in tandem from the proximity to the internal carotid to the dome of the aneurysm. Finally, a fifth curved clip was placed on the previous ones to give them greater closing pressure. Postoperative angiography shows a complete exclusion of the aneurysm with adequate carotid permeability. The postoperative period was excellent, without any neurological deficit. The patient consented with publication of her images and videos.