Let's discuss the tenants for a clip ligation of a small ophthalmic artery aneurysm to illustrate the techniques for ligation of Paraclinoid aneurysms. This is a 26 year-old female with disabling migraines. CT angiogram demonstrated small ophthalmic artery aneurysm. The neck of the aneurysm as expected, was closely related to the anterior Clinoid process. Due to her young age, the patient underwent a left frontotemporal craniotomy and extradural Clinoidectomy, so that the more proximal portion of the neck and the carotid artery are exposed. After completion of the Clinoidectomy, you can see the optic nerve encased by its dura. The hollow area related to the Clinoidectomy, here's again the optic nerve. Last piece of bone over the optic nerve is removed. Here's the extent of the Craniotomy, and minimal dural opening is necessary since this is a relatively small aneurysm and the exposure is primarily subfrontal. Frontal lobe is gently elevated, the optic nerve is identified. CSF is released, and the arachnoid bands over the optic nerve are dissected. Generous opening of the arachnoid bands allows mobilization of the frontal lobe without the use of fixed retractors. Here's the origin of the carotid artery into the intradural space. Here's the small aneurysm. Ultimately, portion of the falciform ligament will be transected for unroofing of the optic nerve and further proximal control over the internal carotid artery. Here's the distal neck of aneurysm, proximal neck. We'll go ahead and cut the falciform ligaments, so we have more exposure on the ICA if necessary. Let's go ahead and use a Carla knife, as you can see here, to open the falciform ligament. A temporary clip was tried just in case it will be necessary. Adequate proximal exposure was confirmed. Here is an angled clip placed across the neck of the aneurysm. The blades are parallel to the long axis of the ICA, the origin of the ophthalmic artery, as you can see here, was carefully protected during clip closure, here's air flora scene. And ICG angiogram demonstrating complete exclusion of the aneurysm with a patency of the surrounding arteries. Again, the ophthalmic artery is readily apparent. Here's the magnified view, a dramatic dissection of the sup frontal area. A piece of temporalis muscle was placed within the Clinoidectomy area to minimize the risk of post operative CSF leakage. The optic nerve should now become pressed. And the postoperative CT angiogram demonstrated complete exclusion of the aneurysm. In this case, no complicating features are apparent on the CT scan and this patient made an excellent recovery. Thank you.
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