Two fundamental approaches exist for the treatment of brain aneurysms: endovascular methods and open surgery. Surgical clipping is the most established of these two, and with decades of accumulated clinical experience behind it, it continues to hold an indispensable place as one of the most critical techniques in neurovascular surgery.
What Is the Basic Principle?
The logic of surgical clipping is straightforward at its core: a small titanium clip is placed across the base — the neck — of the aneurysm sac, permanently cutting off blood flow into the sac. Deprived of its blood supply, the sac gradually thromboses and is excluded from the cerebral circulation. The risk of rupture is thereby eliminated.
How Is the Operation Performed?
Surgical clipping is a microneurosurgical procedure performed under general anesthesia. The operation begins with a craniotomy — the opening of a defined section of the skull. Through this window, the surgeon advances toward the aneurysm under microscopic visualization, navigating between the structures of the brain. Natural anatomical corridors such as the Sylvian fissure are used at this stage, and brain tissue is preserved to the greatest extent possible.
Once the aneurysm is reached, the surgeon carefully dissects the vessels and nerve structures surrounding the neck. After the neck has been sufficiently exposed, a titanium clip of appropriate size and configuration is applied across it using a dedicated applier. To confirm correct clip placement, intraoperative angiography or indocyanine green (ICG) angiography is employed, providing visual verification that the parent artery remains open and the aneurysm sac has been completely excluded.
In Which Situations Is It Preferred?
Surgical clipping is not appropriate for every aneurysm; the decision is made by evaluating both patient and lesion characteristics together. Clipping comes to the forefront in the following situations:
Wide-necked aneurysms that are unsuitable for endovascular coiling are strong candidates for clipping. Middle cerebral artery aneurysms are often more advantageously approached surgically. When an intracerebral hematoma has formed following subarachnoid hemorrhage, both hematoma evacuation and clipping can be performed in the same session. In younger patients, clipping is frequently preferred given its proven long-term durability. Cases where endovascular treatment has failed or recanalization has occurred call for the surgical option.
What Are Its Advantages?
The most significant advantage of surgical clipping is its permanence. A correctly placed clip excludes the aneurysm from the circulation for life, and the risk of long-term recanalization is extremely low. Compared to endovascular methods, the need for annual follow-up angiography is considerably reduced. Furthermore, intraoperative angiography allows clip position to be verified at the moment of surgery and corrected immediately if necessary.
What Are Its Risks?
As with any surgical intervention, clipping carries certain risks. Intraoperative aneurysm rupture is the most serious complication. The possibility of injury to adjacent vessels or nerve structures cannot be disregarded. Craniotomy-related complications such as infection, hemorrhage, and wound issues are also possible. In experienced hands and well-selected cases, these risks remain at an acceptable level, and success rates are consistently high.
Conclusion
Surgical clipping is a treatment method that has matured over decades of accumulated experience, with proven reliability and durability. Even in an era of rapidly advancing endovascular technology, it continues to represent the gold standard for certain aneurysm types and patient groups. The right indication, experienced hands, and meticulous intraoperative assessment form the three cornerstones of a successful clipping procedure.
Prof. Dr. Mehmet Şenoğlu — Neurosurgeon, İzmir
Disclaimer: The information in this article is intended for general informational purposes only. It does not constitute personal medical advice and cannot replace a face-to-face consultation with a physician.