Outcomes for unruptured ophthalmic segment aneurysm surgery

doi:10.1016/j.jocn.2012.12.004

Journal of Clinical Neuroscience

Volume 20, Issue 8, August 2013, Pages 1127-1133

https://doi.org/10.1016/j.jocn.2012.12.004 Get rights and content

Abstract

Ophthalmic segment aneurysms present unique technical challenges because of their proximity to the optic nerve and the anterior clinoid process. The current study was performed to examine whether surgery for unruptured ophthalmic segment aneurysms is an effective treatment modality with acceptable complication rates. A consecutive case series (prospectively collected data) was retrospective reviewed for the period between April 1992 and August 2012. Clinical results, operative complications, angiographic outcomes and prognostic factors associated with surgery are presented. Of the 169 patients with 182 unruptured ophthalmic segment aneurysms that were surgically repaired, 11 (6.4%) experienced new permanent neurological deficits, including six instances of complete visual loss. There was one postoperative death (0.6%) related to a middle cerebral artery infarction. Transient morbidity occurred in 18 patients (10.4%), including cerebrospinal fluid rhinorhea (10 patients), oculomotor nerve palsy (four patients) and transient dysphasia (four patients). A total of 142 aneurysms (78.0%) had documented postoperative angiography. Surgical treatment resulted in 135 (95.1%) complete obliterations and seven (4.9%) neck remnants. Retreatment was performed in three patients (1.7%). Logistic regression analysis of risk factors revealed that age (p < 0.02), aneurysm size (p < 0.01) and the use of temporary clipping (p < 0.01) were significant negative predictors of outcome. The risk associated with surgical repairs for unruptured ophthalmic segment aneurysms is no greater than aneurysms in other locations (6.4% morbidity; 0.6% mortality) and no more hazardous than outcomes achieved by alternative therapies. The robustness of aneurysm repair achieved by open microsurgery is an important consideration.

Introduction

When intervention is deemed appropriate, understanding the risk for aneurysm repair is confounded by the choice between an endovascular option and a microsurgical option. The management of unruptured ophthalmic segment aneurysms remains at the forefront of this controversy. Audits, such as the International Study of Unruptured Intracranial Aneurysms (ISUIA)¹ and the California unruptured aneurysm database² have provided evidence that endovascular therapy may be safer than open microsurgical clipping for many patients with unruptured aneurysms. Such large multi-centre studies can offer statistical power and evidence-based robustness. However, as these studies are audits, the decision biasing the selection of treatments has not been eliminated. Factors influencing the recommendation for a selection of treatment option may also impact upon the risks of this treatment (such as larger size favouring a recommendation to treat by microsurgery rather than endovascular therapy). Contextually important information may explain the differences between modes of treatment, but are often difficult to extract from such multi-centred audits where contexts are subjected to a Gaussian blur. Therefore, treatment recommendations for unruptured intracranial aneurysms cannot be based solely on the results presented in decontextualised audits because the aneurysms selected for microsurgical or endovascular treatment may differ. There remains an important place to combine information from larger audits with case series where contextual richness is preserved.3, 4, 5, 6, 7

We present our experiences with surgical repairs of unruptured ophthalmic segment aneurysms over a 20 year period in an institution that continues to provide microsurgery as a primary treatment modality. Clinical results, complications and prognostic factors for surgical outcomes are presented.

Section snippets

Methods

This study was approved by the Macquarie University Human Ethics Committee and performed in accordance with institutional Ethics Committee guidelines. All patients who underwent treatment of unruptured ophthalmic segment aneurysms by the senior author (M.K.M.) between April 1992 and August 2012 were eligible for review. Data were collected prospectively in a specifically designed database that included patient demographics, clinical presentation, radiological features, aneurysm size and

Results

From April 1992 to August 2012, 198 patients with 217 ophthalmic segment aneurysms were surgically treated by the senior author (M.K.M.). Twenty-nine patients with 35 aneurysms were excluded from the current study, including acute subarachnoid haemorrhages in 16 patients, multiple aneurysms treated in the same operative session (nine patients), fusiform aneurysm (one patient), dissecting aneurysm (one patient) and traumatic aneurysms (two patients). This resulted in a total of 169 patients with

Discussion

In the current study, we analysed 169 patients with 182 unruptured ophthalmic segment aneurysms of the ICA surgically treated in 173 operations by a single surgeon. Our results revealed a procedure-related 6.4% permanent new neurological deficit, 10.4% transient morbidity and 0.6% mortality. Factors that were associated with poor surgical outcomes were recognised for advanced age (>50 years), larger aneurysm size (>15 mm), and when temporary clipping was necessary. When direct surgical clipping

Study limitations

The current study is subjected to a number of limitations. First, while this is a large series of ophthalmic segment artery aneurysms, the results presented in this study reflect a single surgeon’s operative experience over a 20 year period. Examining outcomes over an extended period of time may be difficult to account for changes in operative techniques and technology that may impact on patient care. Microsurgical techniques and neuroanaesthesia has evolved significantly during this period of

Conclusion

Based on our institutional experience, surgical repairs of unruptured ophthalmic segment aneurysms were associated with 6.4% permanent morbidity and 0.6% mortality. The age of the patient (>50 years) and the need for temporary clipping during surgery were associated with a poor outcome. The robustness of aneurysm repair as achieved by open microsurgical repair is an important consideration. For patients with aneurysms less than 15 mm diameter and who are less than 50 years of age the permanent

Conflicts of interest/disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

Acknowledgment

Leon T. Lai has received the Carl Zeiss Doctorate of Philosophy Research Scholarship.

References (37)

D.O. Wiebers et al.
Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment
Lancet
(2003)
S. Asari et al.
Natural history and risk factors of unruptured cerebral aneurysms
Clin Neurol Neurosurg
(1993)
Y. Kumon et al.
Asymptomatic, unruptured carotid-ophthalmic artery aneurysms: angiographical differentiation of each type, operative results, and indications
Surg Neurol
(1997)
M.K. Morgan et al.
Commentary: paraclinoid carotid aneurysms
J Clin Neurosci
(2011)
J. Thornton et al.
Endovascular treatment of paraclinoid aneurysms
Surg Neurol
(2000)
I. Date et al.
Cerebral aneurysms causing visual symptoms: their features and surgical outcome
Clin Neurol Neurosurg
(1998)
K.A. Kattner et al.
Direct surgical management of large bulbous and giant aneurysms involving the paraclinoid segment of the internal carotid artery: report of 29 cases
Surg Neurol
(1998)
J. Zhao et al.
Microneurosurgical management of carotid-ophthalmic aneurysms
J Clin Neurosci
(2006)
S.C. Johnston et al.
Treatment of unruptured cerebral aneurysms in California
Stroke
(2001)
S. Yadla et al.
Open and endovascular treatment of unruptured carotid–ophthalmic aneurysms: clinical and radiographic outcomes
Neurosurgery
(2011)

N.S. Heran et al.

Large ophthalmic segment aneurysms with anterior optic pathway compression: assessment of anatomical and visual outcomes after endovascular coil therapy

J Neurosurg

(2007)

H.K. Park et al.

Endovascular treatment of paraclinoid aneurysms: experience with 73 patients

Neurosurgery

(2003)

M.K. Morgan et al.

Outcome for middle cerebral artery aneurysm surgery

Neurosurgery

(2010)

T. Sampei et al.

Clinical study of growing up aneurysms: report of 25 cases

No Shinkei Geka

(1991)

H. Ujiie et al.

Effects of size and shape (aspect ratio) on the hemodynamics of saccular aneurysms: a possible index for surgical treatment of intracranial aneurysms

Neurosurgery

(1999)

H. Ujiie et al.

Is the aspect ratio a reliable index for predicting the rupture of a saccular aneurysm?

Neurosurgery

(2001)

M. Sonobe et al.

Small unruptured intracranial aneurysm verification study: SUAVe study, Japan

Stroke

(2010)

J.P. Broderick et al.

Greater rupture risk for familial as compared to sporadic unruptured intracranial aneurysms

Stroke

(2009)

Cited by (39)

Endovascular Treatment and Microsurgical Clipping for the Management of Paraclinoid Intracranial Aneurysms: A Systematic Review and Meta-Analysis
2023, World Neurosurgery
We aimed to compare the efficacy and safety of microsurgical clipping versus endovascular treatment (EVT) for paraclinoid aneurysms.
A systematic search for studies including patients with paraclinoid aneurysms treated with a microsurgical or endovascular technique was conducted in 6 databases from inception to February 2022. Efficacy outcomes included complete angiographic occlusion at last follow-up, favorable functional outcome, and recurrence of the aneurysm. For safety, we assessed a composite of intraoperative and postoperative complications. Data were pooled using a random-effects model.
A total of 95 studies including 6711 patients, 3029 in the surgical group and 3682 in the EVT group were found. Pooled rates of complete occlusion were 94% (95% CI 91%–96%; I² = 0%) in the surgical group and 69% (95% CI 63%–74%; I² = 79%) in the EVT group, respectively. The favorable functional outcome rate was 86% (95% CI 76%–92%; I² = 72%) with surgical treatment and 95% (95% CI 92%–97%; I² = 61%) with EVT. The rate of aneurysm recurrence with surgical treatment was 1% (95% CI 0%–4%; I² = 0%) and 12% (95% CI 9%–16%; I² = 57%) with EVT. The composite safety outcome rate in the surgical group was 24% (95% CI 18%–30%; I² = 90%) and 10% (95% CI 8%–13%; I² = 71%) in the EVT group.
Our findings suggest that microsurgical clipping seems to have a higher efficacy than EVT in terms of angiographic occlusion and aneurysm recurrence; however, EVT seems to be safer in terms of intraoperative and postoperative complications. Considering the heterogeneity and low-level evidence of the data available, further prospective randomized studies are warranted to confirm our findings.
Optic Foraminotomy versus Anterior Clinoidectomy for Small Superior-Projecting Paraclinoid Aneurysms: Visual and Angiographic Outcome Evaluation
2023, World Neurosurgery
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.
Paraclinoid aneurysms: Outcome analysis and technical remarks of a microsurgical series
2022, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Citation Excerpt :
A further aspect regards the similar critical reduction of the surgical neurovascular training. Despite this trend, microneurosurgery has proved to hold a primary role in younger patients (<40 years of age), ruptured aneurysms, cases of severely tortuous or stenosed cervical and/or intracranial ICA, and also conditions requiring immediate aneurysms occlusion, as the warning syndromes [3,8–10,12,13,40–54]. In comparison with PED and specifically to the paraclinoid aneurysms, microneurosurgery has also shown a higher and more durable occlusion rate, with an acceptable morbidity [8–17,55].
A critical appraisal of the surgical results of paraclinoid aneurysms is essential in the flow diverters era.
This study overviews the data of a three-decade surgical series of paraclinoid aneurysms while focusing on their technical remarks.
Overall data of a surgical consecutive series of paraclinoid aneurysms treated between 1993 and 2021 were retrospectively reviewed. Aneurysms were classified according to size and projection. Indications for surgery were different based on the availability of endovascular techniques, especially flow diverter, at the time of treatment. A statistical comparison between ruptured and unruptured aneurysms was accomplished.
58 patients were operated upon. Ophthalmic aneurysms were 68%, giant aneurysms 20%, and ruptured aneurysms 45%. Clipping and bypass were executed in 91% and 9% of cases, respectively. An mRS of 0–2 was achieved in 77% of patients, independently by the clinical onset. The mortality rate was 5%. Visual field was improved or unchanged in 71% of elective patients, whereas the incidence of de novo third and sixth cranial nerves deficit was 8% and 5%, respectively. On an average follow-up of 53.3 ± 38 months, a complete and durable aneurysm exclusion was achieved in 91.3% of patients with a single surgery.
Microneurosurgery is still a valuable treatment option for selected ruptured and unruptured paraclinoid aneurysms. In our experience, it has proven to be definitive and durable, with acceptable morbidity and mortality. Clipping is the treatment of choice in most surgical cases, achieving a good visual outcome in symptomatic patients.
Limited Indications for Clipping Surgery of Paraclinoid Aneurysm Based on Long-Term Visual Morbidity
2020, World Neurosurgery
Citation Excerpt :
Removal of the anterior clinoid process and optic strut, and opening of the optic canal, are essential surgical steps for successful clipping of paraclinoid aneurysm. Microneurosurgeons drill or punch these vital osseous structures, mostly intradurally15-20 or extradurally21,22 or both,23,24 based on their expertise, experience, and preference.25 The extradural temporopolar approach (EDTPA) is a modification of Dolenc's extradural trans-cavernous approach with more focus on temporal lobe retraction over the dura mater to reduce the risk of temporal lobe contusion.26,27
Clipping of paraclinoid aneurysm is still challenging because of poor visual morbidity. The extradural temporopolar approach was applied to clip paraclinoid aneurysms, with the expectation of reducing visual morbidity. Factors related to poor visual morbidity were evaluated, to assess the results for clipping of paraclinoid aneurysms.
A series of 40 unruptured paraclinoid aneurysms in 38 patients were clipped via extradural temporopolar approach. Preoperative and postoperative states of visual cognitive function and radiological outcomes were investigated. Aneurysms were classified into dorsal type or non-dorsal type, and small (<9 mm) or not-small (≥9 mm), respectively, to identify factors correlated with visual morbidity.
Complete clipping rate was 90.0% without any recurrence (mean: 5.2 years). Visual morbidity was unexpectedly high at 28.9%, including 2.7% of blindness immediately after the operation, and 23.7% and 2.7% at the final examination (mean: 3.6 years). Multivariate analysis showed aneurysm size was significantly correlated with worse visual outcome. Visual morbidity was 13.3% and 11.1% for dorsal and the non-dorsal small aneurysms, respectively, and all these cases showed visual field defect limited to the nasal quadrant without decreased visual acuity. In contrast, the non-dorsal not-small aneurysms showed significantly worse visual morbidity (60%) with decreased visual acuity.
Clipping via extradural temporopolar approach can achieve durable treatment for small unruptured paraclinoid aneurysms with acceptable visual morbidity. Visual morbidity of the not-small non-dorsal type, however, was poor. The indications for clipping of paraclinoid aneurysm should be limited to small aneurysms, especially the dorsal type in young patients.
Entire Orifice Blocking-Assisted Microsurgical Treatment: Clipping of Intracranial Giant Wide-Neck Paraclinoid Aneurysms
2018, World Neurosurgery
Giant wide-neck paraclinoid aneurysms remain a formidable challenge for neurosurgeons due to the brisk retrograde blood flow during surgical clipping. Theoretically, Entire orifice blockade (EOB) by placing a longitudinal intracarotid balloon catheter across the aneurysm neck could achieve a good vascular control in treating cerebral aneurysms, but related studies have been scarce. The aim of this study was to evaluate the safety and efficiency of the EOB-assisted microsurgical technique for treating giant wide-neck paraclinoid aneurysms.
Clinical data and treatment summaries of patients with giant wide-neck paraclinoid aneurysms who underwent EOB-assisted microsurgical clipping were retrospectively reviewed.
A total of 26 patients were analyzed. All but 3 patients harbored unruptured aneurysms. The mean largest diameter of the aneurysms was 26.8±2.0 mm, and the mean neck size was 12.5±2.4 mm. All lesions were successfully clipped without residual aneurysms. Post-operative images revealed no major branch occlusion due to thromboembolic complications. Four patients presented neurologic deficits caused by vasospasm, 3 of which were completely resolved by postoperative treatment. At a mean follow-up time of 1.86 ± 0.95 years (range, 0.5–3.5 years), none of the patients died, and 96.2% (n = 25) of the patients had favorable clinical outcomes with modified Rankin Scale values of 0–2.
For patients with giant wide-neck paraclinoid aneurysms, EOB-assisted microsurgical clipping is a safe and useful procedure for obtaining vascular control, for softening and shrinking the aneurysm sac and for providing a wide and clean operative field that allows the clip to be effectively placed.
Preoperative Prediction of the Necessity for Anterior Clinoidectomy During Microsurgical Clipping of Ruptured Posterior Communicating Artery Aneurysms
2018, World Neurosurgery
Citation Excerpt :
The medial aspect of the ACP abuts and is indented by the clinoidal segment of the internal carotid artery (ICA).5,6 The necessity of removing the ACP has been emphasized mainly in the management of the paraclinoid region,7-13 but PCoA aneurysms occasionally require removal of the ACP for safe and complete clipping, particularly in ruptured cases wherein proximal control of the ICA before clipping is essential.14-17 Anterior clinoidectomy is one of the complex factors influencing microsurgical management of PCoA aneurysms17; therefore, preoperative prediction of the necessity for removal of the ACP is valuable.
Although most posterior communicating artery (PCoA) aneurysms can be clipped easily with excellent results, some require anterior clinoidectomy for safe and complete clipping.
To review our microsurgical series of ruptured PCoA aneurysms and identify the preoperative predictors for anterior clinoidectomy during microsurgical clipping for PCoA aneurysms.
Results from microsurgical clipping of 104 patients with ruptured PCoA aneurysms were reviewed retrospectively. Distances and angles were obtained from computed tomographic angiography and compared between the anterior and nonanterior clinoidectomy groups.
Anterior clinoidectomy was required in 19 of the 104 cases (18%). None developed surgical complications due to anterior clinoid process (ACP) resection, including postoperative visual deficit. Univariate and multivariate analyses revealed that the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were statistically significant predictive factors for the need of anterior clinoidectomy. Based on a receiver operating characteristic analysis, the distances from the ACP tip to the aneurysmal proximal neck <4.0 mm and from the ACP line to the aneurysmal proximal neck ≤2.0 mm were selected as optimal cutoff values for predicting the necessity of anterior clinoidectomy, and the area under the receiver operating characteristic curve values were 0.991 and 0.955, respectively.
In case of ruptured PCoA aneurysm surgery, the distances from the ACP tip to the aneurysmal proximal neck and from the ACP line to the aneurysmal proximal neck were both found to be useful predictors of whether anterior clinoidectomy was required.

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Clinical StudyOutcomes for unruptured ophthalmic segment aneurysm surgery

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Study limitations

Conclusion

Conflicts of interest/disclosures

Acknowledgment

Lancet

Clin Neurol Neurosurg

Surg Neurol

J Clin Neurosci

Surg Neurol

Clin Neurol Neurosurg

Surg Neurol

J Clin Neurosci

Treatment of unruptured cerebral aneurysms in California

Stroke

Open and endovascular treatment of unruptured carotid–ophthalmic aneurysms: clinical and radiographic outcomes

Neurosurgery

Large ophthalmic segment aneurysms with anterior optic pathway compression: assessment of anatomical and visual outcomes after endovascular coil therapy

J Neurosurg

Endovascular treatment of paraclinoid aneurysms: experience with 73 patients

Neurosurgery

Outcome for middle cerebral artery aneurysm surgery

Neurosurgery

Clinical study of growing up aneurysms: report of 25 cases

No Shinkei Geka

Effects of size and shape (aspect ratio) on the hemodynamics of saccular aneurysms: a possible index for surgical treatment of intracranial aneurysms

Neurosurgery

Is the aspect ratio a reliable index for predicting the rupture of a saccular aneurysm?

Neurosurgery

Small unruptured intracranial aneurysm verification study: SUAVe study, Japan

Stroke

Greater rupture risk for familial as compared to sporadic unruptured intracranial aneurysms

Stroke

Clinical Study
Outcomes for unruptured ophthalmic segment aneurysm surgery