Microsurgical Clipping of a Right Paraclinoid Aneurysm Involving the Distal Dural Ring with Intradural Anterior Clinoidectomy: Step-by-Step Surgical Video

Introduction: Paraclinoid internal carotid artery (ICA) aneurysms involving the distal dural ring are among the most technically demanding lesions in cerebrovascular neurosurgery because of their close relationship with the optic nerve, anterior clinoid process, and carotid branches. Safe microsurgical treatment requires reliable proximal vascular control, adequate exposure of the paraclinoid ICA, precise identification of the aneurysm neck, and meticulous clip reconstruction while preserving adjacent neurovascular structures. This surgical video demonstrates key technical steps for clipping these complex aneurysms. Case Report: A 63-year-old man was incidentally diagnosed with a right paraclinoid ICA aneurysm involving the distal dural ring. A standard right pterional craniotomy was performed. Because of the aneurysm morphology and its close relationship with the distal dural ring, proximal vascular control was first obtained through cervical exposure of the right internal carotid artery. Temporary cervical ICA occlusion was applied during critical stages of dissection to reduce aneurysm wall tension and facilitate safe manipulation of the aneurysm neck. After wide opening of the sylvian fissure, the paraclinoid ICA was exposed. An intradural anterior clinoidectomy was performed using a high-speed drill, allowing removal of the anterior clinoid process and progressive exposure of the distal dural ring. This maneuver increased working space and provided direct visualization of the proximal aneurysm neck. Careful circumferential microsurgical dissection was then performed to define the relationship between the aneurysm, ICA, optic apparatus, and surrounding structures. After complete identification of the aneurysm neck and adequate vascular control, definitive reconstruction was achieved using two permanent aneurysm clips. Clip placement was performed under direct microscopic visualization, with attention to maintaining parent artery patency and preserving adjacent branches. Intraoperative inspection confirmed complete aneurysm exclusion with preservation of the internal carotid artery and its major branches. Results: The patient had an uneventful postoperative course, without neurological deficits and was discharged home 72 hours after surgery. Conclusion: Microsurgical clipping remains an excellent treatment option for selected paraclinoid aneurysms involving the distal dural ring. Cervical proximal carotid control combined with intradural anterior clinoidectomy provides controlled exposure of the paraclinoid ICA and aneurysm neck, reduces tension during dissection, and facilitates precise clip reconstruction. This surgical video highlights the importance of anatomical knowledge, proximal control, careful clinoid drilling, circumferential neck dissection, and preservation of the parent artery for management of these challenging lesions.