Extradural Proximal Control of Internal Carotid Artery for Clipping of a Ruptured Posterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Extradural control of the internal carotid artery in the clinoidal or intracavernous segment affords early proximal control for clipping of paraclinoid and communicating segment aneurysms without the need for a secondary neck incision.1-6 Detailed understanding of skull base anatomy is critical for microsurgical clipping of paraclinoid segment aneurysms. We describe the case of a 60-year-old woman who presented with a Hunt-Hess 2, Fisher 2 subarachnoid hemorrhage secondary to a ruptured posterior communicating artery aneurysm. The patient underwent a cranio-orbital raniotomy, Hakuba "peeling" of the temporal dura propria from the lateral wall of the cavernous sinus, and extradural anterior clinoidectomy. The clinoidal segment of the internal carotid artery (ICA) was secured extradurally for proximal control before dural opening along the sylvian fissure. The proximal sylvian fissure was split and the distal dural ring was dissected. The aneurysm was initially clipped and further explored, with an intraoperative rupture controlled via trapping of the aneurysm with proximal control obtained extradurally in the clinoidal segment of the ICA. Final clipping was performed, and trapping clips were removed. Postoperative imaging showed complete obliteration of the aneurysm, and the patient remained at her neurological baseline. The technical considerations and literature regarding extradural proximal ICA control in the treatment of paraclinoid aneurysms is reviewed. The patient and family provided informed consent for the procedure and consented to the publication of her images. © 2023 Oxford University Press. All rights reserved.