Elsevier

Surgical Neurology

Volume 54, Issue 4, October 2000, Pages 288-299
Surgical Neurology

Endovascular
Endovascular treatment of paraclinoid aneurysms

https://doi.org/10.1016/S0090-3019(00)00313-XGet rights and content

Abstract

BACKGROUND

Paraclinoid aneurysms include those that are distal to the cavernous segment of the internal carotid artery and proximal to the posterior communicating artery. The purpose of this study was to review our experience with the endovascular treatment of this group of aneurysms, which are difficult to treat surgically.

METHODS

Between June 1994 and April 1999, 66 patients (56 female, 10 male) with a mean age of 50.1 years (range 13–75, median 51) underwent endovascular treatment for 71 paraclinoid aneurysms. The mean size of the dome was 8.9 mm (range 3–25 mm, median 7) and the of neck was 3.8 mm (range 1.4–8 mm, median 4). Thirteen patients presented with acute subarachnoid hemorrhage, and 4 with previous subarachnoid hemorrhage. Six aneurysms produced mass effect with visual symptoms, 4 presented with transient ischemic attacks, and 44 were incidental. Nine patients had had previous unsuccessful surgery. All procedures were performed under general anesthesia and with systemic heparinization.

RESULTS

Ninety endovascular procedures were performed on 71 aneurysms: GDC coiling in 78 (including 45 with the remodeling technique), permanent balloon occlusion in 9, and 3 had both GDC coiling and permanent balloon occlusion. In ten aneurysms it was not possible to place coils in the lumen of the aneurysm with the available technology and balloon occlusion was not indicated. Five of these were treated surgically and 5 remain untreated. All patients had immediate post procedure angiography. Of the 61 aneurysms that were treated, 46 (75%) have angiographic follow-up of 6 months or more. Morphological outcome following endovascular therapy for 61 aneurysms at last available follow-up showed > 95% occlusion in 52/61 (85.2%) and <95% in 9/61 (14.8%). Eight patients required surgery, 2 for partial coiling, 2 for refilling of a neck remnant, 2 for persistent mass effect and 2 for coil protrusion. In the 90 procedures performed, 2 (2.2%) patients had major permanent deficits (1 monocular blindness, 1 hemiparesis), 1 (1.1%) had a minor visual field cut, and 2 (2.2%) patients died from major embolic events.

CONCLUSION

Properly selected paraclinoid aneurysms can be successfully treated by endovascular technology. The morbidity and mortality rate of the endovascular approach in our experience is equal to or better than the published surgical series of similar aneurysms. We recommend that the endovascular approach be given primary consideration in the treatment of paraclinoid aneurysms.

Section snippets

Technique

All the procedures are performed under general anesthesia. After arterial vascular access is obtained, systemic heparinization is given with i.v. heparin, 7000 units bolus followed by 1000 units of heparin per hour.

Patient population

We have reviewed the data of 66 patients with 71 paraclinoid aneurysms that were considered suitable for endovascular therapy between June 1994 and April 1999. There were 56 female and 10 male patients. Mean age was 50.1 years (range 13–75 years). The clinical presentation for the 71 aneurysms included 13 with acute subarachnoid hemorrhage (Table 1), 4 with previous subarachnoid hemorrhage, 6 with visual symptoms from mass effect, and 4 with transient ischemic attacks. Forty-four were

Results

A total of 90 endovascular procedures were performed on the 71 aneurysms. There were 78 coiling procedures, which included 45 procedures using the remodeling technique. Nine permanent balloon occlusions were performed. In addition, there were 3 procedures during which both detachable coils were placed and permanent balloon occlusion was performed.

Fifty-eight aneurysms required only one endovascular procedure each. Nine aneurysms required two endovascular procedures each. Two aneurysms required

Classification of paraclinoid aneurysms

We define paraclinoid aneurysms as those that arise from the internal carotid artery distal to the cavernous sinus and proximal to the posterior communicating artery origin. This section of the carotid artery can be called either the ophthalmic segment or the paraclinoid segment and the aneurysms are variously termed ophthalmic, paraophthalmic, carotid cave, paraclinoid, ventral paraclinoid and superior hypophyseal, superior chiasmatic, lateral chiasmatic, infra chiasmatic, supra chiasmatic,

Conclusion

In conclusion, in a series of 71 aneurysms in 66 patients we were able to treat 61 (86%) by endovascular means. We have demonstrated excellent occlusion (>95%) in 87% of these and <95% occlusion in 13%, with a mortality of 2.2% and a morbidity of 3.3%. There was no morbidity associated with unsuccessful attempts at endovascular therapy. Surgery can be performed in those who have had partial or unsuccessful endovascular therapy; likewise, endovascular therapy may be successful in patients with

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