Endoscopic Endonasal Approach for Clipping of Ruptured and Unruptured Paraclinoid Cerebral Aneurysms: Case Report

BACKGROUND AND IMPORTANCE: We present a case in which clip ligation of both a ruptured and an unruptured paraclinoidal segment aneurysm is performed with only the endoscopic endonasal approach in 1 setting. CLINICAL PRESENTATION: A 42-year-old woman, a Hunt and Hess grade 2 patient, presented with aneurysmal subarachnoid hemorrhage. An arteriogram revealed an irregular 10-mm right paraclinoidal aneurysm projecting posteromedially and a 5-mm wide-necked right ophthalmic artery aneurysm projecting superomedially. The patient was taken to the operating room where clipping of both aneurysms was performed through the use of an endonasal endoscopic approach with a pedicled nasoseptal flap reconstruction. Such an approach allowed excellent visualization without drilling of the clinoid process or mobilization of the optic nerve and potential control of the proximal and distal internal carotid artery. An intraoperative arteriogram showed obliteration of both aneurysms with patency of the surrounding vasculature. The patient did well postoperatively and was subsequently discharged home without any neurological deficits. CONCLUSION: An endoscopic endonasal approach was immediately safe and effective for the clipping of both paraclinoidal aneurysms. Although there were benefits achieved from this particular unconventional approach, surgical clipping via traditional craniotomy and endovascular coiling are the established methods of aneurysm treatment and should always be primarily considered. More cases will determine the efficacy and safety of this approach, which should be attempted only by very experienced teams trained in both cerebrovascular and endonasal neurosurgery.