Microsurgical Clipping of Unruptured Aneurysms: The Basics

In the case of elective clipping of unruptured aneurysms, the surgeon has the luxuries of time and careful planning, which he or she should leverage fully to ensure a fully optimized case. Prior to entering the operating theater, it is important to reassess the patient’s history, specifically reviewing their history for any prior subarachnoid hemorrhage (SAH) or cranial trauma, cranial surgery, endovascular therapy – both neurosurgical and otherwise – and medications, including antiplatelets, anticoagulation, and antiepileptics. Next, review all imaging modalities obtained in the workup of their lesion, including catheter-based angiogram, computed tomography angiography, and magnetic resonance angiography. These images should be reviewed with careful attention paid to any vascular variants or anomalies, aneurysm dome projection and configuration, distance from the Sylvian fissure to the aneurysm when applicable, presence of multiple aneurysms, estimating the skull thickness, anterior clinoid process (ACP) anatomy, frontal sinus size and configuration, and cortical veins. Finally, the patient should be asked for any changes in their medical history since their last office visit, and a brief physical examination should be performed.