A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms

doi:10.1016/S0090-3019(97)80415-6

Surgical Neurology

Volume 50, Issue 6, December 1998, Pages 504-520

https://doi.org/10.1016/S0090-3019(97)80415-6 Get rights and content

Abstract

BACKGROUND The treatment of giant and large paraclinoid aneurysms remains challenging. To improve exposure, facilitate the dissection of aneurysms, assure vascular control, reduce brain retraction and temporary occlusion time, enable simultaneous treatment of associated lesions, and achieve more successful treatment of “difficult” (atherosclerotic and calcified) aneurysms, we combined the skull-base approach with endovascular balloon occlusion of the internal carotid artery (ICA) and suction decompression of the aneurysm.

METHODS Sixteen female patients were treated, eight with giant aneurysms and eight with large aneurysms. Eight aneurysms occurred on the right side and eight on the left. Eight patients had an additional aneurysm; five were clipped during the same procedure. Three patients had infundibular arterial dilation. One patient had an associated hemangioma of the ipsilateral cavernous sinus. The cranio-orbital-zygomatic approach was used for all patients. The anterior clinoid was drilled, and the optic nerve was decompressed, dissected, and mobilized. Transfemoral temporary balloon occlusion of the ICA in the neck was followed by placement of a temporary clip proximal to the posterior communicating artery. Suction decompression was then applied. All aneurysms were then successfully clipped, except one that had a calcified neck and wall that could not be collapsed. Intraoperative angiography performed in 13 of 15 patients with clipped aneurysms confirmed obliteration of the aneurysm and patency of the blood vessels.

RESULTS Postoperative results were good in 14 patients. One patient had right-sided hemiplegia and expressive aphasia, which improved after rehabilitation. One patient with an additional basilar tip aneurysm clipped simultaneously died on the fifth postoperative day because of intraventricular hemorrhage. The origin of bleeding could not be determined on autopsy. Surgical difficulties and morbidity stemmed mainly from a severely calcified or atherosclerotic aneurysmal neck.

CONCLUSION The combination of skull-base approaches and endovascular balloon occlusion coupled with suction decompression is a successful option for the treatment of these challenging aneurysms.

Section snippets

Operative technique

Our surgical strategy for patients with giant or large paraclinoid aneurysms can be summarized in three points: 1) the cranio-orbital-zygomatic approach; 2) drilling of the anterior clinoid; and 3) proximal control through transfemoral endovascular balloon occlusion, followed by distal control with a temporary clip, and suction decompression to deflate an aneurysm.

Before the approach began in each patient, electrodes were placed for intraoperative monitoring as follows: a) somatosensory evoked

Case material

During a period of 44 months (September 1993–April 1997), 16 patients with giant or large paraclinoid aneurysms were referred to our institution. Eight of the aneurysms were giant (≥25 mm) and eight were large (15–24 mm). Eight aneurysms were on the right side; eight were on the left side. Neuroradiologic investigation included four-vessel angiography, computed tomography (CT), and magnetic resonance imaging (MRI). Follow-up ranged from 1–44 months. The clinical data are summarized in Table 1.

Treatment

Treating giant or large paraclinoid aneurysms is more difficult than other anterior circulation aneurysms and demands particular operative technique. The risk of treatment is higher and is associated with greater operative hazards. Various techniques for conservative or indirect treatment have been advocated, including carotid occlusion, arterial extracranial-intracranial bypass and subsequent ligation of the ICA with heparinization, wrapping, and intramural thrombosis. Drake et al [14]

Conclusion

A combination of the cranio-orbital zygomatic approach and endovascular transfemoral balloon occlusion with suction decompression proved to be a successful and promising option for treating giant and large paraclinoid aneurysms. We found these techniques particularly useful for raising the upper limit of the treatment of atherosclerotic, thrombosed, and partially calcified aneurysms and for simultaneous treatment of associated aneurysms and tumors.

Acknowledgements

The authors thank Ms. Julie Yamamoto and Dr. B. Lee Ligon for editorial assistance and Mr. Ron M. Tribell for original artwork.

References (47)

J.I Ausman et al.
Giant intracranial aneurysm surgerythe role of microvascular reconstruction
Surg Neurol
(1990)
F.T Charbel et al.
Temporary clipping in aneurysm surgerytechnique and results
Surg Neurol
(1991)
T.C Origitano et al.
Skull base approaches to complex cerebral aneurysms
Surg Neurol
(1993)
L.N Sekhar et al.
A technique of clipping giant intracranial aneurysms with the preservation of the parent artery
Surg Neurol
(1983)
F.K Albert et al.
Combined microneurosurgical and endovascular “trapping evacuation” technique for clipping proximal paraclinoidal aneurysms
Skull Base Surg
(1995)
O Al-Mefty
The cranio-orbital zygomatic approach for intracranial lesions
Contemp Neurosurg
(1992)
O Al-Mefty et al.
Tailoring the cranio-orbital approach
Keio J Med
(1990)
G.M Almeida et al.
Carotid-ophthalmic aneurysms
Surg Neurol
(1976)
H.H Batjer et al.
Surgery for paraclinoidal carotid artery aneurysms
J Neurosurg
(1994)
H.H Batjer et al.
Retrograde suction decompression of giant paraclinoidal aneurysms. Technical note
J Neurosurg
(1990)

H.H Batjer et al.

Use of etomidate, temporary arterial occlusion, and intraoperative angiography in surgical treatment of large and giant cerebral aneurysms

J Neurosurg

(1988)

A.L Day

Aneurysms of the ophthalmic segment. A clinical anatomical analysis

J Neurosurg

(1990)

C.P Derdeyn et al.

Intraoperative digital subtraction angiographya review of 112 consecutive examinations

AJNR

(1995)

V.V Dolenc

Carotid-ophthalmic aneurysms

V.V Dolenc

A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms

J Neurosurg

(1985)

C.G Drake et al.

Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation

J Neurosurg

(1994)

C.G Drake et al.

Carotid-ophthalmic aneurysms

J Neurosurg

(1968)

E.S Flamm

Suction decompression of aneurysms. Technical note

J Neurosurg

(1981)

J.L Fox

Microsurgical treatment of ventral (paraclinoid) internal carotid artery aneurysms

Neurosurgery

(1988)

H Gibo et al.

Microsurgical anatomy of the supraclinoid portion of the internal carotid artery

J Neurosurg

(1981)

B Guidetti et al.

Management of carotid-ophthalmic aneurysms

J Neurosurg

(1975)

R.C Heros et al.

Large and giant paraclinoid aneurysmssurgical techniques, complications, and results

Neurosurgery

(1983)

Y Hosobuchi

Direct surgical treatment of giant intracranial aneurysms

J Neurosurg

(1979)

Cited by (77)

Optic Foraminotomy versus Anterior Clinoidectomy for Small Superior-Projecting Paraclinoid Aneurysms: Visual and Angiographic Outcome Evaluation
2023, World Neurosurgery
Citation Excerpt :
Different techniques have been proposed for this purpose, each one having pros and cons. These include the cervical, petrous, or clinoidal ICA exposure, endovascular balloon-assisted occlusion, suction-decompression technique, adenosine-induced cardiac standstill, and intracavernous control.63-72 Some authors have depicted the control of the petrous ICA as particularly difficult and often inadequate.71-76
Optic foraminotomy (OF) has been recently proposed as an alternative to anterior clinoidectomy (AC) for selected types of paraclinoid aneurysms. In this study, OF and AC were compared for small superior-projecting paraclinoid aneurysms assuming visual and angiographic results as outcome measures. Indications for OF are also discussed.
Data of patients who underwent surgery for a paraclinoid aneurysm in the last 10 years were collected across 3 tertiary hospitals. Small to regular-size and superior projecting aneurysms were sorted. Multiple and complex aneurysms were excluded. Records of patients who went through OF were compared with those of patients who underwent AC. Neurologic outcome was reported as a modified Rankin Scale. Aneurysm complete occlusion rate and rate of approach-related worsened vision were selected as outcome measures of efficacy and safety, respectively, of the OF versus AC. Unpaired t test and χ² test were used for numerical and categorical variables, respectively. A P value less than 0.05 was considered statistically significant.
OF and AC groups involved 18 and 25 patients, respectively. Complication rate, overall neurologic outcome, rate of approach-related worsened vision, and complete occlusion rate did not differ between the groups. The average follow-up was 51 ± 34 and 60 ± 41 months in the OF and AC groups, respectively.
Compared to AC, OF did not show either a higher rate of approach-related worsened vision or a lower aneurysm complete occlusion rate. OF can be considered a valid alternative to the AC for small superior-projecting dorsal ICA wall paraclinoid aneurysms.
An Anatomic Feasibility Study for Revascularization of the Ophthalmic Artery, Part I: Intracanalicular Segment
2020, World Neurosurgery
Citation Excerpt :
This also permits for the lateral mobilization of the OpA with minimal manipulation of the ON and reduces the risk of iatrogenic nerve damage. In our study, proximal control was achieved in the clinoidal portion of the ICA after opening the distal dural ring; however, in clinical practice, the use of proximal ICA control in the cervical or petrous segment or retrograde control using endovascular technique also can be considered.38-40 The use of ATA as a donor vessel has been described previously for an IC-IC bypass in various clinical and cadaveric reports.41-43
The anatomico-functional complexity of the ophthalmic segment aneurysms is attributable to the presence of critical neurovascular structures in the surgical field. Surgical clipping of the ophthalmic artery (OpA) aneurysms can result in postoperative visual deficit due to the complexity of the aneurysm, vasospasm, or optic nerve manipulation. In this study, we aimed to characterize the feasibility of an intracanalicular OpA (iOpA) revascularization with 2 donor vessels: an intracranial-intracranial (IC-IC) bypass using the anterior temporal artery (ATA) and an extracranial-intracranial (EC-IC) bypass using the superficial temporal artery (STA). We further discuss their potential role in “unclippable” OpA aneurysms.
Twenty cadaveric specimens were used to evaluate the operative exposure of the intradural and intracanalicular OpA segments using an extradural-intradural intracanalicular approach. The arterial caliber and length at the anastomotic sites and required donor artery lengths were measured. The feasibility of the bypass using both donors was assessed.
The average length of the intradural and intracanalicular segment of the OpA was 9.5 ± 1.6 mm. The mean caliber of the iOpA was 1.5 ± 0.2 mm. The mean ATA length required for an ATA-OpA anastomosis was 26.7 ± 8.9 mm, with a mean caliber of 1.0 ± 0.1 mm. The mean length of STA required for the bypass was 89.9 ± 9.7 mm, with a mean caliber of 1.92 ± 0.4 mm.
This study confirms the feasibility of iOpA revascularization using IC-IC and EC-IC bypasses. These techniques could potentially be used for prophylactic or therapeutic neuroprotection from retinal ischemic injury while treating complex OpA aneurysms, infiltrative tumors, or intraoperative arterial injuries.
Endoscopic Endonasal Clipping of Anterior Circulation Aneurysm: Surgical Techniques and Results
2018, World Neurosurgery
Endoscopic endonasal clipping of intracranial aneurysms may use microsurgical techniques as an alternative to the transcranial approach. Here we report a series of patients who underwent microsurgical clipping of anterior circulation aneurysms via an endoscopic endonasal approach (EEA).
This retrospective chart review included all the patients who underwent standard binostril EEA for aneurysm clipping. Surgical outcomes and complications are noted. The rationality and limitations of this procedure are discussed.
Seven patients with 12 aneurysms of the anterior circulation underwent EEA for clipping. These 12 aneurysms consisted of 5 anterior communicating artery (AComA) aneurysms, 4 paraclinoid aneurysms, 1 ophthalmic artery aneurysm, and 2 aneurysm located in the cavernous segment of internal carotid artery (ICA). Nine of the 12 aneurysms were successfully clipped. One giant paraclinoid aneurysm could not be clipped during operation and was coiled in second endovascular stage. The 2 aneurysms located in the cavernous segment of ICA were not clipped intentionally in a single-stage procedure, after weighing the surgical benefit against the difficulty of surgical exposure and feasibility. The proximal control of ICA was achieved in all cases. There was no death, no cerebrospinal fluid leak, or other complications. All patients recovered completely.
EEA can provide direct access for microsurgical clipping of strictly selected anterior circulation aneurysms. All the principles of cerebrovascular surgery must be followed. These procedures require a long learning curve. Only teams with adequate experience in microvascular and endoscopic skull base surgeries should attempt this approach for treating aneurysms.
Risk Factors for Visual Impairments in Patients with Unruptured Intradural Paraclinoid Aneurysms Treated by Neck Clipping without Bypass Surgery
2016, World Neurosurgery
Although paraclinoid aneurysms are now frequently referred for endovascular treatment, the durability of obliteration is still to be determined. Therefore, direct surgery for paraclinoid aneurysms still remains indispensable. The present study aimed to evaluate the risk factors for the visual impairments in patients with unruptured intradural paraclinoid aneurysms.
The data of 133 patients with 136 aneurysms treated by neck clipping without bypass surgery was evaluated. Visual impairments included decreased visual acuity and visual field defect. The aneurysm was classified into superior projecting aneurysm, ventral projecting aneurysm, and carotid cave aneurysm. Plug-in method was defined as filling interspace, which was formed between the internal carotid artery and the sutured dura in case of detachment of the dural ring.
Postoperative new visual impairments were observed in 30 aneurysms (22%). During the follow-up period (median, 600 days), postoperative new visual impairments continued in 23 aneurysms (17%). Multivariate analysis showed that carotid cave location and plug-in method were related to new visual impairments at 30 days (odds ratio [OR], 2.6; 95% confidence interval [CI] 1.1–6.1; P = 0.031 and OR, 4.1; 95% CI 1.4–12; P = 0.008) and at 6 months (OR, 4.1; 95% CI 1.5–11; P = 0.005 and OR, 3.3; 95% CI 1.1–11; P = 0.045).
The present study showed that carotid cave location and plug-in method during dural closures were related to postoperative continued visual impairments. Neurosurgeons should carefully consider the surgical indication for unruptured carotid cave aneurysms and avoid plug-in methods.
Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results
2015, World Neurosurgery
Citation Excerpt :
Given the relationship of the ICA with the skull base, dissection of the cervical ICA and/or removal of the anterior clinoid process are usually required to achieve proximal vascular control and prepare the aneurysm neck for clipping. Depending on their site of origin and projection, these aneurysms can also be obscured by the optic nerve, adding the potential morbidity of its inadvertent injury (4-6, 12). Similarly, aneurysms of the vertebrobasilar system remain a formidable challenge for the neurosurgeon because of their rarity and deep location with resultant poor visualization and limited maneuverability (58, 75, 77).
Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may use the same techniques through an alternative corridor. The aim of this article is to report a series of patients who underwent an endoscopic endonasal approach (EEA) for microsurgical clipping of intracranial aneurysms.
We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures are discussed.
Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal internal carotid artery (n = 9) and vertebrobasilar system (n = 2). The internal carotid artery aneurysms projected medially, whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all patients. In all cases, aneurysms were completely occluded. Among complications, 3 patients had postoperative cerebrospinal fluid leakage and 2 other patients had meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms.
EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery, working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.
Aneurysm Clip Compression Technique in the Surgery of Aneurysms with Hard/Calcified Neck
2015, World Neurosurgery
Citation Excerpt :
The goals of aneurysm treatment are the complete and permanent obliteration of the neck with preservation of normal cerebral vasculature and elimination of the mass effect, if present. Most neurosurgeons agree that the best treatment method for aneurysms (especially giant) is direct surgical clipping (1, 8, 17, 18, 21, 34), but this may not always be possible because of their giant size, large neck, intraluminal thrombus, and perforating arteries. One of the most important of these difficulties is the presence of hard/calcified plaque in the aneurysm neck, because this plaque does not allow for proper closure of the clip blades.
One of the most important technical problems in surgery to repair aneurysms is the presence of a hard/calcified neck. In this situation, various techniques can be used for proper clipping. In addition to well-known techniques, we have used a different technique for more than 10 years. This technique probably also has been used by other neurosurgeons, but we could not find any publications about it in the English literature. Therefore, we would like to report the details of this technique and our own experience.
More than 600 anterior circulation aneurysms were clipped between January 2003 and December 2014. It was necessary to apply this technique in 25 aneurysms because of a hard/calcified neck. This series was reviewed retrospectively. If the hard-calcified plaque at the neck does not allow for full closure of the clip and the known techniques are not sufficient for clipping, we carefully and slowly compress the aneurysm clip itself at the neck with a hemostatic clamp. The hard plaque usually is crushed with this technique, and full closure of the clip is immediately obtained.
Complete occlusion of the neck was achieved in 16 aneurysms (64%) with this technique. Technique-related complication developed as intraoperative rupture of the aneurysm in two patients (8%). However, this complication was managed with other techniques in both cases. No distal thromboembolism developed in any patient.
Our aneurysm clip compression technique may be a viable option in surgery of aneurysms with hard-calcified neck.

View all citing articles on Scopus

View full text

Original ArticlesA combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms

Abstract

Section snippets

Operative technique

Case material

Treatment

Conclusion

Acknowledgements

Surg Neurol

Surg Neurol

Surg Neurol

Surg Neurol

Combined microneurosurgical and endovascular “trapping evacuation” technique for clipping proximal paraclinoidal aneurysms

Skull Base Surg

The cranio-orbital zygomatic approach for intracranial lesions

Contemp Neurosurg

Tailoring the cranio-orbital approach

Keio J Med

Carotid-ophthalmic aneurysms

Surg Neurol

Surgery for paraclinoidal carotid artery aneurysms

J Neurosurg

Retrograde suction decompression of giant paraclinoidal aneurysms. Technical note

J Neurosurg

Use of etomidate, temporary arterial occlusion, and intraoperative angiography in surgical treatment of large and giant cerebral aneurysms

J Neurosurg

Aneurysms of the ophthalmic segment. A clinical anatomical analysis

J Neurosurg

Intraoperative digital subtraction angiographya review of 112 consecutive examinations

AJNR

Carotid-ophthalmic aneurysms

A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms

J Neurosurg

Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation

J Neurosurg

Carotid-ophthalmic aneurysms

J Neurosurg

Suction decompression of aneurysms. Technical note

J Neurosurg

Microsurgical treatment of ventral (paraclinoid) internal carotid artery aneurysms

Neurosurgery

Microsurgical anatomy of the supraclinoid portion of the internal carotid artery

J Neurosurg

Management of carotid-ophthalmic aneurysms

J Neurosurg

Large and giant paraclinoid aneurysmssurgical techniques, complications, and results

Neurosurgery

Direct surgical treatment of giant intracranial aneurysms

J Neurosurg

Original Articles
A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms