Picket fence technique for clip reconstruction of complex intracranial aneurysms

Complex intracranial aneurysms characterized by wide necks, calcifications, intraluminal thrombus formation, irregular dome morphology, and involvement of critical branch vessels pose a formidable challenge for neurosurgeons. The "picket fence" clipping technique is an advanced clip reconstruction strategy for complex intracranial aneurysms. The technique involves stacked parallel clips (fenestrated or simple) oriented vertically such that the tip of the blade reconstructs the aneurysm neck. This study reports the largest single-surgeon series using picket fence clip reconstruction for complex intracranial aneurysm treatment.

A retrospective review of all aneurysms treated with picket fence clipping from 1998 to 2024 identified 41 patients. Demographic data, aneurysm characteristics, operative details, perioperative complications, aneurysm occlusion rates, and clinical outcomes using the modified Rankin Scale (mRS) score were recorded for descriptive analysis.

Of the aneurysms, 80% (33/41) were in the anterior circulation, and 34% (14/41) were ruptured at presentation. The median admission mRS score was 0.5 (IQR 0-3), which remained stable at the most recent follow-up (median 0, IQR 0-3). Aneurysm occlusion was achieved in 88% (36/41) without branch vessel compromise from clipping. Recurrence was noted in 2 aneurysms, necessitating retreatment with bypass for flow augmentation. Good neurological outcomes (mRS score ≤ 2) occurred in 63% (26/41) of patients, whereas permanent neurological morbidity occurred in 9% (4/41). Four patients with complex aneurysms had undergone prior endovascular treatment; 3 patients had undergone prior failed attempts at coiling.

This study reports the largest experience of picket fence aneurysm clipping, demonstrating that the technique is safe and effective for treating complex intracranial aneurysms. The clipping procedure is associated with robust aneurysm neck reconstruction, vessel patency, and favorable clinical outcomes. The technique warrants broader neurosurgical adoption in selective aneurysms unsuitable for conventional clipping.