Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

  • Lee, Sang Kook (Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine) ;
  • Kim, Jae Min (Department of Neurosurgery, Hanyang University Guri Hospital, Hanyang University College of Medicine)
  • Received : 2013.05.29
  • Accepted : 2013.12.12
  • Published : 2013.12.28
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Abstract

Objective : Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications. Methods : Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography. Results : Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely. Conclusion : The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.

Keywords

References

  1. Barami K, Hernandez VS, Diaz FG, Guthikonda M : Paraclinoid Carotid Aneurysms : Surgical Management, Complications, and Outcome Based on a New Classification Scheme. Skull Base 13 : 31-41, 2003 https://doi.org/10.1055/s-2003-37551
  2. Batjer HH, Kopitnik TA, Giller CA, Samson DS : Surgery for paraclinoidal carotid artery aneurysms. J Neurosurg 80 : 650-658, 1994 https://doi.org/10.3171/jns.1994.80.4.0650
  3. Beretta F : The paraclinoid aneurysms and the distal dural ring : a new classification. J Neurosurg Sci 48 : 161-175, 2004
  4. Chang DJ : The "no-drill" technique of anterior clinoidectomy : a cranial base approach to the paraclinoid and parasellar region. Neurosurgery 64 (3 Suppl) : ons96-ons105; discussion ons105-ons106, 2009 https://doi.org/10.1227/01.NEU.0000341714.55023.8F
  5. Colli BO, Carlotti CG Jr, Assirati JA Jr, Abud DG, Amato MC, Dezena RA : Results of microsurgical treatment of paraclinoid carotid aneurysms. Neurosurg Rev 36 : 99-114; discussion 114-115, 2013 https://doi.org/10.1007/s10143-012-0415-0
  6. Coscarella E, BaŞkaya MK, Morcos JJ : An alternative extradural exposure to the anterior clinoid process : the superior orbital fissure as a surgical corridor. Neurosurgery 53 : 162-166; discussion 166-167, 2003 https://doi.org/10.1227/01.NEU.0000068866.22176.07
  7. De Jesús O, Sekhar LN, Riedel CJ : Clinoid and paraclinoid aneurysms :surgical anatomy, operative techniques, and outcome. Surg Neurol 51 : 477-487; discussion 487-488, 1999 https://doi.org/10.1016/S0090-3019(98)00137-2
  8. Dolenc VV : A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms. J Neurosurg 62 : 667-672, 1985 https://doi.org/10.3171/jns.1985.62.5.0667
  9. Figueiredo EG, Tavares WM, Rhoton AL Jr, De Oliveira E : Surgical nuances of giant paraclinoid aneurysms. Neurosurg Rev 33 : 27-36, 2010 https://doi.org/10.1007/s10143-009-0224-2
  10. Froelich SC, Aziz KM, Levine NB, Theodosopoulos PV, van Loveren HR, Keller JT : Refinement of the extradural anterior clinoidectomy : surgical anatomy of the orbitotemporal periosteal fold. Neurosurgery 61 (5 Suppl 2) : 179-185; discussion 185-186, 2007
  11. Fulkerson DH, Horner TG, Payner TD, Leipzig TJ, Scott JA, Denardo AJ : Endovascular retrograde suction decompression as an adjunct to surgical treatment of ophthalmic aneurysms : analysis of risks and clinical outcomes. Neurosurgery 64 (3 Suppl) : ons107-ons111; discussion ons111-ons112, 2009 https://doi.org/10.1227/01.NEU.0000335176.98788.A1
  12. Gonzalez LF, Walker MT, Zabramski JM, Partovi S, Wallace RC, Spetzler RF : Distinction between paraclinoid and cavernous sinus aneurysms with computed tomographic angiography. Neurosurgery 52 : 1131-1137; discussion 1138-1139, 2003 https://doi.org/10.1227/01.NEU.0000058465.98426.2E
  13. Hashimoto K, Nozaki K, Hashimoto N : Optic strut as a radiographic landmark in evaluating neck location of a paraclinoid aneurysm. Neurosurgery 59 : 880-895; discussion 896-897, 2006 https://doi.org/10.1227/01.NEU.0000232664.02190.E1
  14. Heros RC, Nelson PB, Ojemann RG, Crowell RM, DeBrun G : Large and giant paraclinoid aneurysms : surgical techniques, complications, and results. Neurosurgery 12 : 153-163, 1983 https://doi.org/10.1227/00006123-198302000-00004
  15. Hoh BL, Carter BS, Budzik RF, Putman CM, Ogilvy CS : Results after surgical and endovascular treatment of paraclinoid aneurysms by a combined neurovascular team. Neurosurgery 48 : 78-89; discussion 89-90, 2001
  16. Iihara K, Murao K, Sakai N, Shindo A, Sakai H, Higashi T, et al. : Unruptured paraclinoid aneurysms : a management strategy. J Neurosurg 99 : 241-247, 2003 https://doi.org/10.3171/jns.2003.99.2.0241
  17. Javalkar V, Banerjee AD, Nanda A : Paraclinoid carotid aneurysms. J Clin Neurosci 18 : 13-22, 2011 https://doi.org/10.1016/j.jocn.2010.06.020
  18. Khan N, Yoshimura S, Roth P, Cesnulis E, Koenue-Leblebicioglu D, Curcic M, et al. : Conventional microsurgical treatment of paraclinoid aneurysms : state of the art with the use of the selective extradural anterior clinoidectomy SEAC. Acta Neurochir Suppl 94 : 23-29, 2005 https://doi.org/10.1007/3-211-27911-3_5
  19. Kim JM, Romano A, Sanan A, van Loveren HR, Keller JT : Microsurgical anatomic features and nomenclature of the paraclinoid region. Neurosurgery 46 : 670-680; discussion 680-682, 2000 https://doi.org/10.1097/00006123-200003000-00029
  20. Kobayashi S, Kyoshima K, Gibo H, Hegde SA, Takemae T, Sugita K : Carotid cave aneurysms of the internal carotid artery. J Neurosurg 70 : 216-221, 1989 https://doi.org/10.3171/jns.1989.70.2.0216
  21. Kolasa PP, Kaurzel Z, Lewinski A : Treatment of giant paraclinoid aneurysms. Own experience. Neuro Endocrinol Lett 25 : 287-291, 2004
  22. Li J, Lan ZG, Liu Y, He M, You C : Large and giant ventral paraclinoid carotid aneurysms : surgical techniques, complications and outcomes. Clin Neurol Neurosurg 114 : 907-913, 2012 https://doi.org/10.1016/j.clineuro.2012.01.039
  23. Margalit NS, Lesser JB, Moche J, Sen C : Meningiomas involving the optic nerve : technical aspects and outcomes for a series of 50 patients. Neurosurgery 53 : 523-532; discussion 532-533, 2003 https://doi.org/10.1227/01.NEU.0000079506.75164.F4
  24. Mathiesen T, Kihlström L : Visual outcome of tuberculum sellae meningiomas after extradural optic nerve decompression. Neurosurgery 59 : 570-576; discussion 570-576, 2006 https://doi.org/10.1227/01.NEU.0000228683.79123.F9
  25. Murayama Y, Sakurama K, Satoh K, Nagahiro S : Identification of the carotid artery dural ring by using three-dimensional computerized tomography angiography. Technical note. J Neurosurg 95 : 533-536, 2001 https://doi.org/10.3171/jns.2001.95.3.0533
  26. Nanda A, Javalkar V : Microneurosurgical management of ophthalmic segment of the internal carotid artery aneurysms : single-surgeon operative experience from Louisiana State University, Shreveport. Neurosurgery 68 : 355-370; discussion 370-371, 2011 https://doi.org/10.1227/NEU.0b013e3182039819
  27. Noguchi A, Balasingam V, Shiokawa Y, McMenomey SO, Delashaw JB Jr : Extradural anterior clinoidectomy. Technical note. J Neurosurg 102 : 945-950, 2005 https://doi.org/10.3171/jns.2005.102.5.0945
  28. Nutik SL : Ventral paraclinoid carotid aneurysms. J Neurosurg 69 : 340-344, 1988 https://doi.org/10.3171/jns.1988.69.3.0340
  29. Pia HW : Classification of aneurysms of the internal carotid system. Acta Neurochir (Wien) 40 : 5-31, 1978 https://doi.org/10.1007/BF01773112
  30. Raco A, Frati A, Santoro A, Vangelista T, Salvati M, Delfini R, et al. : Long-term surgical results with aneurysms involving the ophthalmic segment of the carotid artery. J Neurosurg 108 : 1200-1210, 2008 https://doi.org/10.3171/JNS/2008/108/6/1200
  31. Rhoton AL Jr : Aneurysms. Neurosurgery 51 (4 Suppl) : S121-S158, 2002
  32. Son HE, Park MS, Kim SM, Jung SS, Park KS, Chung SY : The avoidance of microsurgical complications in the extradural anterior clinoidectomy to paraclinoid aneurysms. J Korean Neurosurg Soc 48 : 199-206, 2010 https://doi.org/10.3340/jkns.2010.48.3.199
  33. Thornton J, Aletich VA, Debrun GM, Alazzaz A, Misra M, Charbel F, et al. : Endovascular treatment of paraclinoid aneurysms. Surg Neurol 54 : 288-299, 2000 https://doi.org/10.1016/S0090-3019(00)00313-X
  34. Wang Y, Li Y, Jiang C, Jiang F, Meng H, Siddiqui AH, et al. : Endovascular treatment of paraclinoid aneurysms : 142 aneurysms in one centre. J Neurointerv Surg 5 : 552-556, 2013 https://doi.org/10.1136/neurintsurg-2012-010494
  35. Xu BN, Sun ZH, Romani R, Jiang JL, Wu C, Zhou DB, et al. : Microsurgical management of large and giant paraclinoid aneurysms. World Neurosurg 73 : 137-146; discussion e17, e19, 2010 https://doi.org/10.1016/j.surneu.2009.07.042
  36. Xu D, Pollock M : Experimental nerve thermal injury. Brain 117 (Pt 2) : 375-384, 1994 https://doi.org/10.1093/brain/117.2.375
  37. Yang Y, Wang H, Shao Y, Wei Z, Zhu S, Wang J : Extradural anterior clinoidectomy as an alternative approach for optic nerve decompression : anatomic study and clinical experience. Neurosurgery 59 (4 Suppl 2) : ONS253-ONS262, 2006
  38. Yasargil MG, Fox JL : The microsurgical approach to intracranial aneurysms. Surg Neurol 3 : 7-14, 1975
  39. Zipfel GJ, Day AL : Surgical treatment of clinoid and ophthalmic segment internal carotid artery aneurysms in Le Roux PD, Winn HR, Newell DW (eds) : Management of cerebral aneurysms. Philadelphia : Saunders, 2004, pp731-744