Microsurgical clipping of paraclinoid aneurysms: a 12-year single-centre experience with surgical nuances and...

Paraclinoid aneurysms, arising from the internal carotid artery between the proximal dural ring and the posterior communicating artery, pose significant microsurgical challenges due to their proximity to critical neurovascular structures. Despite advances in endovascular techniques, surgical clipping offers definitive exclusion with lower recurrence. This study evaluates surgical outcomes and operative nuances in clipping paraclinoid aneurysms over a 12-year period. A retrospective review was conducted of 116 patients with paraclinoid aneurysms who underwent surgical clipping at a tertiary centre between 2011 and 2023. Data on demographics, clinical presentation, aneurysm morphology, surgical strategy, and outcomes were analysed. The outcome was assessed using the modified Rankin Scale (mRS), with a favourable outcome defined as mRS 0-2. A p-value < 0.05 was considered significant. Informed consent was obtained from all the patients. Among 116 patients median age at presentation was 48 (38.25-59.75) years, 80.2% presented with subarachnoid haemorrhage (SAH). Most had good preoperative status (Hunt & Hess grade I-II: 63.8%; mRS 0-2: 66.4%). Clipping was performed in 84.5%, with alternative strategies including trapping (8.6%) and wrapping (3.4%). Anterior clinoidectomy was required in 70.7% (intradural: 41.4%, extradural: 29.3%). Intraoperative rupture occurred in 20.7%, and multiple clips were used in 27.6%. Postoperative complications included infarcts (23.3%), vasospasm (32.8%), and seizures (7.8%). At discharge, 58.6% had favourable outcome; mortality was 17.2%, increasing to 23.3% at final follow-up. Visual outcomes were better after extradural clinoidectomy, with improvement in 32.4% versus 4.2% for intradural approach. Microsurgical clipping remains a viable, effective treatment for paraclinoid aneurysms, particularly in younger patients and ruptured cases. Extradural anterior clinoidectomy may confer superior visual outcomes. Despite technical complexity, favourable functional outcomes (mRS 0-2) were achieved in 64.6% of patients, underscoring the continued relevance of surgical management in appropriately selected cases.