Surgery by Dr. Javier Ibáñez
Intradural clinoidectomy is one of the most highly valued techniques in modern vascular neurosurgery, especially in the treatment of aneurysms of the carotid-ophthalmic segment and the superior hypophyseal artery. In this case, uploaded to the online surgery app SurgSchool, presented by the Dr. Javier Ibanez (Son Espases Hospital, Palma de Mallorca), the surgical strategy applied to a young patient with a small aneurysm diagnosed incidentally is explained step by step.
Clinical context of the case
The 33-year-old patient was diagnosed with a cerebral aneurysm after experiencing a severe headache without evidence of subarachnoid hemorrhage. Due to a family history of aneurysmal hemorrhage and the patient's explicit preference, surgical treatment was chosen.
Direct coiling was ruled out due to the small size of the aneurysm, as was stent placement, prioritizing open resolution.
Objectives of the surgical approach
This case illustrates two fundamental pillars of the management of supraclinoid carotid segment aneurysms:
- Intradural clinoidectomy to expose the optic canal, the supraclinoid carotid artery, and the distal dural ring.
- Opening and handling of dural rings to gain safe access to the neck of the aneurysm.
The preserved anatomy of the case facilitates the didactic demonstration of the technique, including the relationship between the optic nerve, internal carotid artery, and surrounding bone structures.
Intradural clinoidectomy: key steps
During the procedure, the Dr. Ibáñez performs:
1. Exposure of the third cranial nerve, supraclinoid carotid artery, and optic pathway
A wide field is obtained without excessive retraction of the frontal or temporal lobes.
2. Double-arch dural incisions
They allow complete exposure of the clinoid and optic canal, guaranteeing direct visual control throughout the milling process.
3. Milling of the anterior clinoid process
Are used diamond burs to minimize risk to delicate structures such as the optic nerve.
Intradural milling generates debris, so constant irrigation is required to keep the subarachnoid space clean.
4. Clinoid mobilization
Once freed from its three anchor points (optic canal, sphenoidal wing, and optic pillar), it is carefully removed, taking into account the proximity of the oculomotor nerve.
Opening of the distal dural ring
The distal dural ring is selectively sectioned, especially in its medial portion, allowing mobilization of the carotid artery and access to the superior hypophyseal artery aneurysm.
The anatomy of the clinoid segment, the origin of the ophthalmic artery, and the space between the carotid artery and the optic nerve where these lesions are located are clearly identified.
Exposure of the aneurysm and clipping
The aneurysm appears with a well-defined neck.
Dr. Ibáñez introduces a fine dissector to anticipate the trajectory of the clip blades, taking into account the frequent collision with the bony base of the skull.
A slightly curved miniclipChecking the closure and readjusting it to obtain an optimal result.
Flow control is verified with intraoperative Doppler, as indocyanine green was not available at that time.
Finally, the follow-up angiography confirms a satisfactory result without complications.
Educational importance of the case
This procedure is especially relevant for residents and neurosurgeons interested in:
- Carotid-ophthalmic segment surgery
- Surgical anatomy of the dural rings
- Clinoidectomy techniques
- Microsurgical management of paraclinoid aneurysms
- Clipping strategies in small aneurysms
The full video by Dr. Ibáñez shows each step in detail, allowing you to understand the anatomical sequence and the surgical logic of the approach.
Access this complete surgery at SurgSchool
This surgery is available on the app SurgSchool, the leading surgical training platform in Spanish and English, with high-quality videos narrated by international experts in neurosurgery, ENT and interventional procedures.
