Overcoming Daunting Challenges of Clipping of Paraclinoid Carotid-Ophthalmic and Superior Hypophyseal Artery Aneurysms: 2-Dimensional Operative Video

This surgical video emphasizes the nuances that needed to overcome daunting challenges of clipping of paraclinoid carotidophthalmic and superior hypophyseal artery (SHA) aneurysms. To avoid hazardous manipulations, scarifying the ipsilateral SHA under visual evoked potential (VEP) guidance can be done without risk of postoperative visual decline. This technique is associated with better visual outcome.(1) A 66-yr-old woman presented with gradually enlarging right paraclinoid carotidophthalmic and SHA aneurysms. The relationship between those aneurysms and the critical neurovascular structures made us facing a daunting challenge to preserve the visual function. To preserve the patency of the ophthalmic artery (oph.A), endovascular intervention was abandoned and a direct clipping surgery was selected. Following VEP settings, exposure of the cervical internal carotid artery for proximal control and right frontotemporal craniotomy, a subfrontal approach was used. To get adequate accessibility and safe maneuverability, the anterior clinoidectomy and unroofing of the optic canal were completed, then, the falciform ligament and the distal dural ring were carefully opened. Under VEP guidance, the oph.A and SHAs were temporarily occluded. VEP had been stable under repeated occlusions. The carotidophthalmic aneurysm was clipped with preservation of the oph.A. Besides, 1 ipsilateral SHA was sacrificed to achieve complete clipping of the SHA aneurysm. Final indocyanine green videoangiography confirmed obliteration of the paraclinoid aneurysms and patency of the oph.A, the other SHA and the tiny arterioles around the optic nerve. The postoperative course was uneventful. There was no evidence of postoperative visual disturbances. The patient has consented to the submission of the case report to the journal.