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