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Results of microsurgical treatment of paraclinoid carotid aneurysms

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Abstract

The term “paraclinoid aneurysms”, has been used for aneurysms of the internal carotid artery (ICA) between the cavernous sinus and the posterior communicating artery. Due to their complex anatomical relationship at the skull base and because they are frequently large/giant, their surgical treatment remains a challenge. Ninety-five patients harboring 106 paraclinoid aneurysms underwent surgery (1990–2010). Age, 11–72 years old. Sex, 74:21 female/male. Follow-up; 1–192 months (mean = 51.7 months). Eighty-six patients had single and 9 had multiple paraclinoid aneurysms. Sixty-six were ophthalmic, 14 were in the ICA superior wall, 13 in the inferior, 10 in the medial, and 3 in the ICA lateral wall. Eleven were giant, 29 were large, and 66 were small. Sixty-three patients had ruptured and 32 had unruptured aneurysms. Two patients with bilateral aneurysms had bilateral approaches, totaling 97 procedures. A total of 98.2 % of aneurysms were clipped (complete exclusion in 93.8 %). ICA occlusion occurred in 10 (5.6 %). There was no patient rebleeding during the follow-up period. A good outcome was achieved in 76.8 %, with better results for unruptured aneurysms, worse results for patients with vasospasm, and with no difference according to size. Thirty-six (37.9 %) patients had transient/permanent postoperative neurological deficits (25.4 % ruptured vs. 62.5 % unruptured aneurysms). The most frequent deficits were visual impairment and third cranial nerve palsies. Operative mortality was 11.6 %, all in patients presenting with ruptured aneurysms. Despite relatively high morbidity/mortality, especially for patients with ruptured aneurysms, microsurgical treatment of paraclinoid aneurysm has high efficacy, with better outcome for unruptured aneurysms and worse outcome for patients with vasospasm.

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Correspondence to Benedicto Oscar Colli.

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Atul Goel, Mumbai, India

In the era where interventional neuroradiological procedures are gaining firm footage, a surgical series dealing with ‘paraclinoid’ aneurysms presents a breath of fresh air. No matter what, surgery on paraclinoid aneurysms is technically difficult and challenging. Any complication can be life threatening. Identification of the exact location of the aneurysm in relationship to the anterior clinoid process, dural sleeves or rings of the clinoidal segment of the internal carotid artery and cavernous sinus on the basis of ‘high-quality’ imaging are obvious pre-requisites. Although some surgeons prefer to have a control of carotid artery in the neck or at the petrous apex whilst dealing with such aneurysms, more experienced surgeons avoid such an additional surgical maneuver. Wide exposure is the key to success. Drilling of the anterior clinoid process and exposure of entire segment of the artery in the paraclinoid region and whenever necessary in the distal part of the cavernous sinus forms the basis of surgical success. Drilling of the anterior clinoid process can be difficult and dangerous in the presence of adjoining aneurysm and needs to be performed with extreme care and high degree of technical efficiency. Safety of the third and second cranial nerves and of the first division of the trigeminal nerve is paramount during the process of anterior clinoid process drilling. The aneurysm can sometimes be pointing medially in the ‘Kobayashi’s carotid dural cave’ of the region and accordingly present difficulty in exposure. The aneurysms pointing superiorly or rostrally are generally more difficult to operate as such aneurysms are more often associated with a broad neck and thin dome or are ‘blister-like’. In general, laterally projecting aneurysms in this location are safer. The perforators and ophthalmic artery emerging from this segment of the artery need to be preserved with diligent dissection. Mirror contralateral aneurysms, particularly when they are unruptured, can sometimes be surgically treated through the ipsilateral surgical exposure. However, any perceived danger in such an exposure should prohibit the surgeon from such an endeavour as a surgical mishap can certainly be ‘ugly’. The authors have identified no difference in surgical outcome between large and small aneurysm and ruptured and unruptured aneurysms. This is certainly a variation from the generally observed norm. Despite the encouraging results of the authors and despite the fact the surgery on such cases is enterprising; my belief is that interventional procedures will take precedence in the future. However, surgery will continue to have a role in more complex aneurysms, not amenable to interventional procedures and in cases where revascularization surgical procedures are necessary.

Vinko V. Dolenc, Ljubljana, Slovenia

The anatomy–coursing of the ICA in the entire skull base–is clear and so are the extradural and the intradural ICA segments. It is very questionable that one is stating that “while aneurysms arising from the proximal intracranial carotid artery...” Intracranial ICA from the entry point into the petrous canal runs in the skull base extradurally through the bone(s) and then through the parasellar space–cavernous sinus, and finally looping around the ACP it does enter the intradural space at the distal dural ring (DR). According to my personal experience, only a few “paraclinoid” or better carotid ophthalmic aneurysms (COAs) extended partially into the extradural space and not vice versa as it is stated in this report. It has been published in many papers already what the COA’s characteristics are, how they present themselves clinically and what the necessary preoperative examinations are. The statement that these aneurysms were treated under the surgical microscope nowadays is not even necessary–since no intracranial aneurysm is dealt with without magnification anymore. It is also well known that proximal control is necessary if this is at the neck or in the petrous bone or with the Dallas technique endovascularly or with extradural exposure of the ICA at the anterior loop of it is dependent on the experience of the surgeon. The results of the treatment are well analyzed, including all the complications. Mortality was rather high (11.6 %). In the discussion, it is difficult to agree with the author that small contralateral COAs could be easily clipped in case of bilateral paraclinoid aneurysms. It does depend on the chiasm if it is at normal position or if the chiasm is prefixed or postfixed. I do agree with the authors when they put in the conclusion that “morbidity and mortality can be reduced with increasing experience of the surgeon and with improvement in the microsurgical techniques and incorporation of technology for the identification of patients who will need revascularisation to prevent direct cranial nerve lesions and ischemia due to vessel occlusions”. This is very true. This report does present a positive attempt toward the improvement of treatment of COAs. However, more neuroanatomical laboratory practice would help to achieve better results. Only five COAs per year is simply a rather low number to accumulate enough experience. That is why laboratory work is of paramount importance. The authors have to be congratulated for presenting their knowledge, experience, and all the effort to achieve better results. However, the learning curve could be accelerated with continuous work in the neuroanatomy laboratory.

Anil Nanda, Vijayakumar Javalkar, Shreveport, USA

Ophthalmic segment aneurysms of the ICA constitute around 5 % of the all the intracranial aneurysms. Giant, multiple, and bilateral aneurysms are more frequent in this subset of aneurysms. These aneurysms are technically challenging due to the adjacent bony anatomy, dural attachments, and the close proximity of the visual apparatus. This is a large retrospective series. In this series, standard pterional approach was used in 31 procedures, and in 4 of them, the anterior clinoid process was partially removed intradurally. The extra/intradural approach with resection of the anterior clinoid process was used in 66 procedures. There is no consensus regarding the routine use of cranial base approaches. We feel that in majority of the cases a standard pterional craniotomy with flattening of the sphenoid ridge is sufficient and routine drilling of ACP is not needed in all cases. Ischemic complications are an important cause for morbidity and mortality. In this paper the most common cause of death was thrombosis of the ICA in 45 % followed by vasospasm (37 %). It is not clear from the paper if the authors have attempted any revascularization procedures. We agree with the author’s statement that the use of intraoperative microDoppler and revascularization strategies might bring down the complications related to the ICA thrombosis. In addition to these techniques, the intraoperative indocyanine green angiogram is a very useful tool to assess the patency of the parent vessel and efficacy of clipping. Another observation from this paper is low incidence of postoperative hydrocephalus (5 %). Authors attribute it to the routine opening of lamina terminalis during the surgery. The authors need to be congratulated on their excellent technical results.

Shigeaki Kobayashi, Matsumoto, Japan

Colli et al. report a large series of paraclinoid aneurysms of the internal carotid artery (ICA) operated on by open microsurgical clipping. The authors treated this type of aneurysms with clipping-first policy, which is relatively rare nowadays in Japan as an increasing number of cases are treated endovascularly. Nevertheless, this report offers a useful information in terms of anatomical and surgical considerations. Possible complications and mortality specific for surgery of those aneurysms would serve a good reference. The following are some of my comments on this paper, having similarly experienced a large number of paraclinoid aneurysms.

1. As the authors state, aneurysms in this region are called differently and there is still not a standard nomenclature. Among various names, paraclinoid aneurysms are increasingly more often used, partly because interventionists do not need to know detailed regional anatomy as those intending an open surgical clipping. As mentioned by the authors, Batjer proposed to define paraclinoid aneurysms as those located between the roof of the cavernous sinus and the origin of the posterior communicating artery. The roof of the cavernous sinus is, however, difficult to determine on the angiogram or on other imaging means, and also at surgery due to the complex topographic anatomy of the region where the ICA penetrates the distal dural ring. So that the paraclinoid aneurysms may better be simply defined as those including some of ICA aneurysms at the level of the anterior clinoid process, actually aneurysms located in C-2,3 portion.

2. The authors classify the paraclinoid aneurysms into ‘superior’, ‘inferior’, ‘medial’ and ‘lateral’ types without defining them. I would assume that the authors’ classification is based on the direction of the aneurysm on the anteroposterior (AP) and lateral view of the angiogram. If so, ‘medial’ and ‘lateral’ types of the paraclinoid aneurysms are understandable from the AP view. However, the ‘superior and inferior’ types of the paraclionid aneurysms are not always easy to understand. Because the ICA after penetrating the distal dural ring curves three-dimensionally in a complex fashion. The aneurysm is sometimes located anteriorly in the perpendicularly ascending part of the ICA curve. ‘Superior’ type of aneurysms can then be called anterior type. When pterionally approached, ‘superior’ aneurysms could be called superolateral or dorsal type in the operative field. The ‘lateral’ aneurysm on the other hand would be superiorly pointing toward the surgeon in the pterionally approached field. Similar confusion can be mentioned as to the ‘inferior type’ of aneurysms as well.

3. The authors state that the most frequent postoperative deficits were visual impairment (13.7 %) with regard to amaurosis and decreased vision. If the visual field deficits without decreased acuity are included, the visual complications would be more.

4. Regarding indication for surgery, more and more patients are nowadays treated endovascularly in Japan, because those aneurysms are often not associated with an arterial branching point, making it easier to coil. Secondly, coiling carries less likelihood of postoperative coil compaction unlike in aneurysms at the branching points where flow stress would be stronger.

5. In seven cases, contralaterally located paraclinoid aneurysms were clipped at the time of clipping ipsilateral aneurysms (ruptured or giant) in the present series. In our experience, many single paraclinoid aneurysms (unruptured) were clipped contralaterally with less postoperative visual complications than with ipsilateral approach.

6. Postoperative ICA occlusion/thrombosis occurring at a high rate (10.5 %) in the present series is a matter of concern, which may cause death or severe operative sequerae. Intraoperative angiography, Doppler flowmetry, intraoperative indocyanine green angiogram study are now available, which may serve as a tool to confirm vascular patency, and should be used more often. One needs to keep in mind, however, that depending too much on one method could be risky. More than anything else, good surgical exposure availing intraoperative reconstructive procedures at rupture or difficulty, preventive bypass procedures could also be employed as necessary.

7. Visual impairment occurred in association with anterior clinoidectomy especially with extradural clinoidectomy, which is difficult to understand because the optic apparatus is protected by the dural ring when approached extradurally. In our practice, we mostly use intradural clinoidectomy in the case of aneurysms because inadvertent rupture of the aneurysm can better be prevented under direct vision, and secondly the extent of the clinoid removal can be more adequately judged according to the local anatomy in relation to the aneurysm as the authors state.

In conclusion, this paper offers useful information for those who operate on this type of aneurysm by clipping method. It cannot be overstressed that meticulous planning and careful procedures will be a key to success in clipping those aneurysms, considering the results of improving endovascular treatment.

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Colli, B.O., Carlotti, C.G., Assirati, J.A. et al. Results of microsurgical treatment of paraclinoid carotid aneurysms. Neurosurg Rev 36, 99–115 (2013). https://doi.org/10.1007/s10143-012-0415-0

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