Types of Aneurysm Clipping Surgery

Aneurysm clipping surgery is a critical and life-saving procedure used to treat brain aneurysms bulging, weakened areas in the walls of cerebral arteries that can rupture and cause bleeding in the brain. When diagnosed in time, aneurysms can be managed through surgical interventions that prevent rupture and protect brain function. Among these, aneurysm clipping remains a gold-standard treatment, especially for accessible aneurysms that pose a high risk of rupture.

What is Aneurysm Clipping Surgery?

Before diving into the various types, it’s essential to understand types of aneurysm clipping surgery involves.

Aneurysm clipping is a type of open brain surgery (craniotomy) where the neurosurgeon places a small metal clip at the base of the aneurysm. This clip blocks blood flow into the aneurysm sac, effectively isolating it from the normal circulation and preventing it from rupturing. The clip remains permanently in place, providing a mechanical solution to a potentially fatal condition.

This technique has been in use since the 1930s and has evolved considerably with modern technology and surgical expertise.

Why Clipping Over Other Procedures?

Aneurysm clipping is generally preferred in certain scenarios:

• When the aneurysm is located in an accessible part of the brain

• When the aneurysm has a wide neck or complex structure

• For younger patients where long-term durability is important

• When other treatments like coiling are less effective

Now, let’s break down the main types and variations of aneurysm clipping surgery, each tailored to the aneurysm’s size, shape, and location.

Types of Aneurysm Clipping Surgery

1. Standard Microsurgical Clipping Overview :- This is the traditional and most common form of aneurysm clipping surgery. It involves creating a craniotomy (a bone flap in the skull), exposing the aneurysm using an operating microscope, and carefully applying the titanium clip across the neck of the aneurysm.Key Features
   • Uses high-powered operating microscopes
   • Performed under general anesthesia
   • Involves direct visualization of the aneurysm
   • Offers high success rates, especially for unruptured aneurysms

   Ideal For

   • Middle cerebral artery aneurysms
   • Anterior communicating artery aneurysms
   • Posterior communicating artery aneurysms

   Advantages

   • Long-term durability
   • Visual confirmation of clip placement
   • Suitable for wide-neck aneurysms
2. Keyhole Clipping Surgery (Minimally Invasive) Overview :- Keyhole clipping is a less invasive variation of traditional clipping. Instead of a large craniotomy, this approach uses a small, strategically placed opening (usually above the eyebrow or behind the hairline) to reach the aneurysm.Key Features
   • Smaller incision (2–3 cm)
   • Less bone and brain exposure
   • Quicker recovery times
   • Reduced hospital stay and scarring

   Ideal For

   • Small to medium-sized aneurysms
   • Aneurysms located in the anterior circulation
   • Patients requiring minimal cosmetic impact

   Advantages

   • Reduced trauma to surrounding brain tissue
   • Shorter recovery
   • Lower risk of complications

   Keyhole surgery demands exceptional skill and advanced imaging for preoperative planning, and not all aneurysms are suitable for this approach.

3. Endoscopic-Assisted Clipping Overview :- In this method, a small endoscope (a thin tube with a camera and light) is used alongside traditional microscopic techniques to visualize hard-to-see aneurysms or surrounding brain structures.Key Features
   • Combines the benefits of endoscopy and microscopy
   • Offers superior angles for viewing deep or narrow corridors
   • Helps in clipping aneurysms located near vital structures

   Ideal For

   • Deep-seated aneurysms
   • Aneurysms near the brainstem or cranial nerves
   • Complex, multilobed aneurysms

   Advantages

   • Enhanced visualization without larger exposure
   • Precise clip placement
   • Lower risk of damaging surrounding structures

   Endoscopic assistance is not a standalone procedure but a powerful adjunct to standard clipping in difficult cases.

4. Multiple Clip Technique Overview :- Certain aneurysms, especially those that are large, complex, or have more than one lobe, require multiple clips for effective occlusion. This method is referred to as the multiple clip technique.Key Features
   • Use of 2 or more clips to occlude large or irregular aneurysms
   • Clipping is done at multiple angles
   • Careful consideration to avoid impeding blood flow in parent vessels

   Ideal For

   • Giant aneurysms (>25 mm)
   • Fusiform or multilobed aneurysms
   • Wide-necked aneurysms

   Advantages

   • Flexibility in managing complex cases
   • More complete aneurysm exclusion
   • Avoidance of partial clipping or residual aneurysm neck

   This approach demands high surgical experience, preoperative imaging, and intraoperative tools like Doppler ultrasound or indocyanine green (ICG) angiography to confirm complete occlusion.

5. Intraoperative Imaging-Guided Clipping Overview :- Modern surgical suites are now equipped with intraoperative imaging technologies like ICG angiography, fluorescein video angiography, or intraoperative digital subtraction angiography (DSA) to assess the efficacy of the clipping in real time.Key Features
   • Live feedback on blood flow
   • Helps verify complete aneurysm closure
   • Reduces the need for revision surgeries

   Ideal For

   • Any aneurysm type where accuracy is critical
   • Aneurysms near major branches or perforating vessels

   Advantages

   • Enhances safety
   • Helps avoid clipping normal arteries
   • Improves outcomes, especially in complex surgeries

   This isn’t a different surgical type per se, but a crucial enhancement that significantly improves the precision of any clipping surgery.

How Surgeons Choose the Right Type

The choice of clipping technique depends on several factors:

• Aneurysm characteristics :- size, location, neck width, shape

• Patient health :- age, comorbidities, neurological status

• Surgical access :- how deep or difficult the aneurysm is to reach

• Surgeon expertise :- experience and available technology

• Urgency :- ruptured vs. unruptured aneurysm

Each case is assessed individually using advanced imaging tools such as CT angiography, MR angiography, and cerebral DSA before surgery is planned.

Conclusion

Aneurysm clipping surgery continues to evolve with technology, becoming more refined, precise, and tailored to each patient. From standard microsurgical clipping to innovative keyhole and endoscopic-assisted techniques, the field offers a variety of approaches suited to the complexity of the aneurysm and the patient’s needs.

While endovascular coiling has gained popularity, clipping still remains the definitive choice for many aneurysm types, especially those requiring a permanent and reliable solution.

Choosing the right type of clipping surgery depends on a collaborative decision between patient and neurosurgeon, guided by imaging, clinical factors, and surgical goals. With the right approach, aneurysm clipping offers high success rates, low recurrence, and the chance to live a full life free from the threat of rupture.