Clinoidectomía anterior intradural para clipado de aneurisma paraclinoideo izquierdo: video quirúrgico / Anterior intradural clinoidectomy for clipping left paraclinoid aneurysm: surgical video

Introducción: Los aneurismas paraclinoideos representan un verdadero desafío microquirúrgico para su resolución. Objetivo: Presentamos el caso de una mujer de 43 años de edad con cefalea, detectando en angiografía aneurisma paraclinoideo izquierdo. Material y métodos: Se realizó abordaje pterional izquierdo y exposición de carótida interna a nivel cervical, durotomía arciforme con apertura de cisterna silviana hacia cisterna carotídea. Se expone la apófisis clinoides anterior, observándose en el video, el aneurisma naciendo del segmento clinoideo de la arteria carótida interna, siendo imposible el clipado de la misma sin clinoidectomía anterior. Se secciona la duramadre desde medial respecto al conducto óptico hasta la apófisis clinoides. Se realiza fresado en la base de la apófisis clinoides para exponer el anillo dural distal. Se libera la carótida en el segmento clinoideo a través de la sección del anillo dural distal para poder movilizarla. Identificado el cuello distal y proximal del aneurisma, se comienza la reconstrucción colocando un clip a 90° en dirección anteroposterior, un segundo clip en dirección posteroanterior y al punzar el aneurisma se constata flujo aneurismático presente. Se coloca un tercer y cuarto clip en tándem desde la proximidad a la carótida interna hacia el domo del aneurisma. Finalmente se posiciona un quinto clip curvo sobre los anteriores para darles mayor presión de cierre. Resultados: Se observa angiografía postoperatoria con exclusión completa el aneurisma con adecuada permeabilidad carotidea. El período postoperatorio fue excelente, sin déficit neurológico. La paciente brindo consentimiento para publicar sus imágenes y videos.

Introduction: Paraclinoid aneurysms represent a true microsurgical challenge. Objective: We present the case of a 43-year-old woman with headache, in whom a left paraclinoid aneurysm was detected by angiography. Methods and Materials: A left pterional approach was adopted, combined with exposing the internal carotid artery at the cervical level, and an arciform durotomy with the opening of the sylvian fissure to the carotid cistern. The anterior clinoid process was exposed, revealing the aneurysm originating from the clinoid segment of the carotid artery; consequently, clipping was impossible without an anterior clinoidectomy. The dura was cut medially from the optic canal to the clinoid process. Drilling was performed at the base of the clinoid process to expose the distal carotid dural ring. The carotid was released in the clinoid segment by sectioning the distal dural ring to mobilize it. After identifying the distal and proximal neck of the aneurysm, reconstruction was initiated by placing a 90-degree clip in the anteroposterior direction; then, a second clip in the posteroanterior direction and puncturing the aneurysm, demonstrating that aneurysmal flow was present. Third and fourth clips were placed in tandem, one proximal to the internal carotid and the other at the dome of the aneurysm. Finally, a fifth curved clip was placed over the previous clips to increase their closure pressure. Results: Postoperative angiography revealed complete exclusion of the aneurysm with adequate carotid permeability. The postoperative period lacked any complications or neurological deficits. The patient consented to have her images and videos published. Conclusions: Combining a left pterional approach with exposing the internal carotid artery at the cervical level and performing an arciform durotomy at the sylvian fissure's opening into the carotid cistern, an angiographically-detected left paraclinoid aneurysm was treated successfully with an excellent outcome.

Effect analysis of different treatment modalities in patients with paraclinoid aneurysm / 中国脑血管病杂志

Objective To investigate the clinical effects and related complications of surgical and endovascular treatments of paraclinoid aneurysms. Methods Seventy-two consecutive patients with paraclinoid aneurysm admitted to the Department of Neurosurgery, the First Affiliated Hospital of Soochow University were enrolled retrospectively. They were confirmed by head and neck CT angiography and DSA examination,including 45 females and 27 males. According to the different treatment modalities, 72 patients were divided into endovascular embolization group ( n=38,stent-assisted coil embolization) and microsurgery group (n=34,including aneurysm clipping or intracranial and extracranial vascular bypass plus trapping of aneurysms). The baseline data and aneurysm diameter of both groups were recorded and analyzed. Baseline data included age,sex,cranial nerve injury,Hunt-Hess grade,etc. The new cranial nerve injury,aneurysm recurrence and Glasgow outcome scale ( GOS) scores were compared between the two groups,and the size of recurrent and non-recurrent aneurysms were analyzed. The age, aneurysm diameter,and prognostic score were compared in patients with Hunt-Hess grade Ⅲ-Ⅳ in both groups. Results (1 ) The age of patients in the endovascular embolization group was older than that in the microsurgery group (60 ±10 years vs. 54 ± 10 years,t= -2. 490),the diameter of aneurysms was smaller than that of microsurgery group (5[4,8] mm vs. 9[5,16] mm,Z=3. 026). There were significant differences between the two groups ( all P <0. 05 ) . There were no significant differences in gender, incidence of visual impairment and Hunt-Hess grading between the two groups (all P >0. 05). (2) The patients of both groups were followed up for 6 months. There were no significant differences in GOS score, improvement of postoperative visual acuity,and immediate visual impairment after surgery ( all P>0. 05). The recurrence rate of aneurysms in the endovascular embolization group was higher than that in the microsurgery group. The difference was statistically significant between the two groups (18. 4%[7/38] vs. 2. 9%[1/34], χ2=4. 350,P<0. 05). (3) In the endovascular embolization group, the diameter of aneurysm in recurrent patients was larger than that in non-recurrent patients,and the difference was statistically significant between the two groups (10[8,15] mm vs. 5[3,7] mm,Z = -2. 356, P<0. 05). (4) For aneurysm patients with Hunt-Hess grade Ⅲ-Ⅳ, the GOS score of the endovascular embolization group was lower than that of the microsurgery group,and the difference was statistically significant (4[3,4] vs. 5[4,5],Z= -2. 282,P<0. 05]. Conclusion For paraclinoid aneurysms,the recurrence rate of aneurysms with microsurgical treatment is lower than that of endovascular embolization,and is beneficial to the prognosis of patients with Hunt-Hess grade Ⅲ-Ⅳ.

Aneurismas paraclinoideos: experiencia personal de 1 año en el Hospital Regional de Temuco / Paraclinoid aneurysm: 1 year personal experience at Hospital Regional de Temuco

Se presenta la experiencia personal en el tratamiento de 5 pacientes con 7 aneurismas paraclinoideos tratados quirúrgicamente en el Hospital Regional Temuco durante junio de 2015 y julio de 2016 (13 meses). Todos los pacientes fueron previamente discutidos con neurorradiologo Intervencional local y considerados no favorables para terapia endovascular. En todos ellos se realizó una craneotomía mini pterional con clinoidectomía extradural y exposición de la arteria carótida interna cervical. Cuatro pacientes consultaron con hemorragia subaracnoidea y requirieron cirugía cerebral de urgencia. En 6 aneurismas se realizó clipaje y en 1 trapping. Cuatro pacientes no tuvieron deterioro neurológico y evolucionaron favorablemente mientras que 1 paciente falleció por hipoperfusión secundario al trapping de la carótida supraclinoidea. Se enfatiza el manejo interdisciplinario, el plan preoperatorio y el conocimiento de la neuroanatomía en el tratamiento de esta patología.

A personal experience is presented in treating 5 patients with 7 paraclinoid aneurysm who underwent surgery at Hospital Regional Temuco between june 2015 and july 2016 (13 months). All patients were previously discussed with local interventional neuroradiologist considering them not favorable to endovascular therapy. Mini pterional craniotomy with extradural clinoidectomy and internal cervical carotid artery exposure was performed in all of them. 4 patients presented with subarachnoid hemorrhage and required urgent brain surgery. Direct clipping was optimal in 6 aneurysm and 1 was treated with trapping. 4 patients had no neurological deteriotation with excellent outcome and 1 patient died because of hypoperfusion secondary to the supraclinoid carotid trapping. Interdisciplinary management, preoperative planning and neuroanatomy knowledge are emphasized in order to treat this pathology.

Intra-arterial Thrombolysis for Central Retinal Artery Occlusion after the Coil Embolization of Paraclinoid Aneurysm

The most common complication of coil embolization for cerebral aneurysms is thrombo-embolic stroke; in rare cases, these strokes, can present with central retinal artery occlusion. At our institution, a 53-year-old woman underwent stent-assisted coiling of the aneurysm. The patient's vision was improved immediately after intra-arterial thrombolysis and had further improved 8 months later. This report describes our experience of a rare case of central retinal artery occlusion after coil embolization that was successfully treated by intra-arterial thrombolysis.

Microcatheter Looping to Facilitate Aneurysm Selection in Coil Embolization of Paraclinoid Aneurysms

OBJECTIVE: Described herein is a microcatheter looping technique to facilitate aneurysm selection in paraclinoid aneurysms, which remains to be technically challenging due to the inherent complexity of regional anatomy. MATERIALS AND METHODS: This retrospective study was approved by our Institutional Review Board, and informed consent was waived. Microcatheter looping method was employed in 59 patients with paraclinoid aneurysms between January 2012 and December 2013. In the described technique, construction of a microcatheter loop, which is steam-shaped or pre-shaped, based on the direction of aneurysms, is mandatory. The looped tip of microcatheter was advanced into distal internal carotid artery and positioned atop the target aneurysm. By steering the loop (via inner microguidewire) into the dome of aneurysm and easing tension on the microcatheter, the aneurysm was selected. Clinical and morphologic outcomes were assessed with emphasis on technical aspects of the treatment. RESULTS: Through this looping technique, a total of 59 paraclinoid aneurysms were successfully treated. After aneurysm selection as described, single microcatheter technique (n = 25) was most commonly used to facilitate coiling, followed by balloon protection (n = 21), stent protection (n = 7), multiple microcatheters (n = 3), and stent/balloon combination (n = 3). Satisfactory aneurysmal occlusion was achieved through coil embolization in 44 lesions (74.6%). During follow-up of 53 patients (mean interval, 10.9 +/- 5.9 months), only one instance (1.9%) of major recanalization was observed. There were no complications related to microcatheter looping. CONCLUSION: This microcatheter looping method facilitates safe and effective positioning of microcatheter into domes of paraclinoid aneurysms during coil embolization when other traditional microcatheter selection methods otherwise fail.

Clinical Outcome of Paraclinoid Internal Carotid Artery Aneurysms After Microsurgical Neck Clipping in Comparison with Endovascular Embolization

OBJECTIVE: Because of the complex anatomical association among vascular, dural, and bony structures, paraclinoid internal carotid artery (ICA) aneurysms remain a major challenge for vascular neurosurgeons. We studied the clinical outcomes of 61 paraclinoid ICA aneurysms after microsurgical clipping in comparison with endovascular coiling. MATERIALS AND METHODS: Between January 2008 and December 2012, we treated 61 paraclinoid ICA aneurysms created by surgical clipping or endovascular coiling. Preoperative neurologic status and postoperative outcome were evaluated using the Glasgow coma scale (GCS) and the modified Rankin scale (mRS). Postoperative hydrocephalus and vasospasm were reviewed using the patients' medical charts. RESULTS: Most patients were in good clinical condition before the operations and had good treatment outcomes. Clinical vasospasm was observed after the operation in five patients, and hydrocephalus occurred in six patients. No statistically significant difference regarding aneurysm size, sex, GCS score, H-H grade, and mRS was observed between the surgical clipping group and the endovascular coiling group. In addition, the treatment results and complications did not show statistically significant difference in either group. CONCLUSION: Surgical occlusion of paraclinoid ICA aneurysms is difficult; however, no significant differences were observed in the treatment results or complications when compared with coil embolization. In particular, use of an adequate surgical technique may lead to better outcomes than those for coil embolization in the treatment of large and/or wide-neck paraclinoid ICA aneurysms.

Angiographic and Clinical Result of Endovascular Treatment in Paraclinoid Aneurysms / 신경중재치료의학

PURPOSE: The purpose of this study was to analyze the results of an immediate and mid-term angiographic and clinical follow-up of endovascular treatment for paraclinoid aneurysms. MATERIALS AND METHODS: From January 2002 to December 2012, a total of 113 consecutive patients (mean age: 56.2 years) with 116 paraclinoid saccular aneurysms (ruptured or unruptured) were treated with endovascular coiling procedures. Clinical and angiographic outcomes were retrospectively evaluated. RESULTS: Ninety-three patients (82.3%) were female. The mean size of the aneurysm was 5.5 mm, and 101 aneurysms (87.1%) had a wide neck. Immediate catheter angiography showed complete occlusion in 40 aneurysms (34.5%), remnant sac in 51 (43.9%), and remnant neck in 25 (21.6%). Follow-up angiographic studies were performed on 80 aneurysms (69%) at a mean period of 20.4 months. Compared with immediate angiographic results, follow-up angiograms showed no change in 38 aneurysms, improvement in 37 (Fig. 2), and recanalization in 5. There were 6 procedure-related complications (5.2%), with permanent morbidity in one patient. CONCLUSION: Out study suggests that properly selected patients with paraclinoid aneurysms can be successfully treated by endovascular means.

Use of the Sundt Clip Graft in a Previously Coiled Internal Carotid Artery Blister-Like Aneurysm

Owing to the focal wall defect covered with thin fibrous tissues, an aneurysm arising from the dorsal wall of the internal carotid artery (ICA) is difficult to manage either surgically or endovascularly and is often associated with high morbidity and mortality. Unfortunately, the definitive treatment modality of such highly risky aneurysm has not yet been demonstrated. Upon encountering the complex intracranial pathophysiology of such a highly precarious aneurysm, a neurosurgeon would be faced with a challenge to decide on an optimal approach. This is a case of multiple paraclinoid aneurysms including the ICA dorsal wall aneurysm, presented with spontaneous subarachnoid hemorrhage. With respect to treatment, direct clipping with a Sundt graft clip was performed after multiple endovascular interventions had failed. This surgical approach can be a treatment modality for a blood blister-like aneurysm after failed endovascular intervention(s).

The Pterional Approach and Extradural Anterior Clinoidectomy to Clip Paraclinoid Aneurysms

OBJECTIVE: The surgical clipping of paraclinoid segment internal carotid artery aneurysms is considered difficult because of the complex anatomical location and important neighboring structures. Our experiences of pterional craniotomy and extradural anterior clinoidectomy (EAC) to clip paraclinoid aneurysms are reported herein. METHODS: We present two patients with paraclinoid aneurysms who underwent surgical clipping using pterional craniotomy and EAC. The clinical results and operative techniques were reviewed from the patients' medical records. RESULTS: EAC improves the surgical field in the suprasellar and periclinoid regions. Clinically, a good outcome was obtained in both cases. No surgical complications directly resulting from the EAC were observed. CONCLUSION: Favorable surgical results can be obtained with pterional craniotomy and EAC for the clipping of paraclinoid aneurysms. EAC is advocated for the clipping of paraclinoid aneurysms.

Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

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.

Distinction between Intradural and Extradural Aneurysms Involving the Paraclinoid Internal Carotid Artery with T2-Weighted Three-Dimensional Fast Spin-Echo Magnetic Resonance Imaging

OBJECTIVE: The precise intra- vs. extradural localization of aneurysms involving the paraclinoid internal carotid artery is critical for the evaluation of patients being considered for aneurysm surgery. The purpose of this study was to investigate the clinical usefulness of T2-weighted three-dimensional (3-D) fast spin-echo (FSE) magnetic resonance (MR) imaging in the evaluation of unruptured paraclinoid aneurysms. METHODS: Twenty-eight patients with unruptured cerebral aneurysms in their paraclinoid regions were prospectively evaluated using a T2-weighted 3-D FSE MR imaging technique with oblique coronal sections. The MR images were assessed for the location of the cerebral aneurysm in relation to the dural ring and other surrounding anatomic compartments, and were also compared with the surgical or angiographic findings. RESULTS: All 28 aneurysms were identified by T2-weighted 3D FSE MR imaging, which showed the precise anatomic relationships in regards to the subarachnoid space and the surrounding anatomic structures. Consequently, 13 aneurysms were determined to be intradural and the other 15 were deemed extradural as they were confined to the cavernous sinus. Of the 13 aneurysms with intradural locations, three superior hypophyseal artery aneurysms were found to be situated intradurally upon operation. CONCLUSION: High-resolution T2-weighted 3-D FSE MR imaging is capable of confirming whether a cerebral aneurysm at the paraclinoid region is intradural or extradural, because of the MR imaging's high spatial resolution. The images may help in identifying patients with intradural aneurysms who require treatment, and they also can provide valuable information in the treatment plan for paraclinoid aneurysms.

The Avoidance of Microsurgical Complications in the Extradural Anterior Clinoidectomy to Paraclinoid Aneurysms

OBJECTIVE: Paraclinoid segment internal carotid artery (ICA) aneurysms have historically been a technical challenge for neurovascular surgeons. The development of microsurgical approach, advances in surgical techniques, and endovascular procedures have improved the outcome for paraclinoid aneurysms. However, many authors have reported high complication rates from microsurgical treatments. Therefore, the present study reviews the microsurgical complications of the extradural anterior clinoidectomy for treating paraclinoid aneurysms and investigates the prevention and management of observed complications. METHODS: Between January 2004 and April 2008, 22 patients with 24 paraclinoid aneurysms underwent microsurgical direct clipping by a cerebrovascular team at a regional neurosurgical center. Microsurgery was performed via an ipsilateral pterional approach with extradural anterior clinoidectomy. We retrospectively reviewed patients' medical charts, office records, radiographic studies, and operative records. RESULTS: In our series, the clinical outcomes after an ipsilateral pterional approach with extradural anterior clinoidectomy for paraclinoid aneurysms were excellent or good (Glasgows Outcome Scale : GOS 5 or 4) in 87.5% of cases. The microsurgical complications related directly to the extradural anterior clinoidectomy included transient cranial nerve palsy (6), cerebrospinal fluid leak (1), worsened change in vision (1), unplanned ICA occlusion (1), and epidural hematoma (1). Only one of the complications resulted in permanent morbidity (4.2%), and none resulted in death. CONCLUSION: Although surgical complications are still reported to occur more frequently for the treatment of paraclinoid aneurysms, the permanent morbidity and mortality resulting from a extradural anterior clinoidectomy in our series were lower than previously reported. Precise anatomical knowledge combined with several microsurgical tactics can help to achieve good outcomes with minimal complications.

Imaging of Distal Dural Ring Plane and Paraclinoid Internal Carotid Artery Aneurysms with 3D Rotational Angiography / 신경중재치료의학

PURPOSE: The distal dural ring (DDR) plane separates the intradural from extradural paraclinoid internal carotid artery (ICA) aneurysm. The purpose of this study was to evaluate the feasibility of the localization of the DDR plane drawn by the bony landmarks in patients with paraclinoid ICA aneurysms at 3D rotational angiography (3DRA). MATERIALS AND METHODS: 13 consecutive patients who underwent a 3DRA for the evaluation of 16 paraclinoid ICA aneurysms were reviewed retrospectively. On a dedicated workstation, multiplanar reconstruction (MPR) image along the virtual plane of DDR was reconstructed from the mask run image of 3DRA. Three bony landmarks were used to locate virtual plane of DDR: tuberculum sellae, inferior root of anterior clinoid process (ACP) and supero-medial aspect of optic strut. The MPR image was fused with 3D volume-rendered reconstruction image. Medial and posterior inclination angle of virtual plane of DDR was measured. The location of the paraclinoid ICA aneurysm was categorized into indradural, transdural, and extradural. RESULTS: In all cases, the DDR plane was identified and the relationship between the DDR plane and the paraclinoid ICA aneurysm was successfully determined on fusion image of 3DRA mask and contrast runs by dual volume visualization. The aneurysm locations determined with 3DRA were 8 intradural, 6 transdural and 2 extradural. The medial and posterior inclination angles of DDR plane ranged at 8 to 43degrees(mean 17.4degrees), and -2 to 20degrees(mean 6.4degrees), respectively. CONCLUSION: Localization of the paraclinoid ICA aneurysm in relation to the virtual plane of DDR is feasible with 3DRA and dual volume visualization.

Analysis of Clinical Outcome and Complications After Microsurgical Clipping of Unruptured Paraclinoid Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: The study reports the clinical outcomes and complication rates of microsurgical clipping of unruptured paraclinoid aneurysms. METHODS: From July 1997 to December 2008, 61 patients underwent microsurgical clipping for 61 unruptured paraclinoid aneurysms in our institute. Entire medical records, radiographic data, and operation records were reviewed retrospectively. RESULTS: After the microsurgical clipping, complete obstruction was achieved in 56 patients (91.8%). Visual disturbance (nine cases, 14.8%) was the most frequent complication. Overall, 59 patients (96.7%) had a good long-term outcome (Glasgow outcome scale score of 4-5 3 months post-operatively). CONCLUSION: For patients with paraclinoid aneurysms, satisfactory outcomes can be achieved by microneurosurgical management. These results will be useful when considering treatment of an unruptured paraclinoid aneurysm.

Clinical and Radiogical Outcomes of Endovascular Detachable Coil Embolization in Paraclinoid Aneurysms : A 10-Year Experience

OBJECTIVE: Direct surgical clipping of paraclinoid aneurysms poses technical challenges to even very experienced neurosurgeons, making endovascular treatment an alternative treatment modality in many centers. We have therefore retrospectively evaluated the safety and efficacy of endovascular detachable coil embolization of paraclinoid aneurysms. METHODS: From June 1997 to June 2007, 65 patients underwent endovascular detachable coiling for 67 paraclinoid aneurysms (of which 9 were ruptured and 58 were unruptured) in our institute. Their medical records, radiological images and readings, and operation records were reviewed retrospectively. RESULTS: After the initial embolization procedure, complete occlusion was achieved in 29 (43.3%) of the aneurysms treated by endovascular detachable coiling. Six aneurysms required retreatment, with two each requiring one, two, or three additional endovascular procedures. Fifty-five (82.1%) aneurysms were measured by three-dimensional time of flight (TOF) magnetic resonance images (MRI) or transfemoral cerebral angiography (TFCA) at a mean follow-up of 29.7 months (range from 4 to 94 months), with 39 aneurysms (70.9%) showing complete occlusion. Thromboembolic events (3.8%) were the most frequent complication. Rupture did not occur during or after any of the procedures. According to the Glasgow Outcome Scale (GOS), 98.4% of the patients treated by coil embolization had a score of 4 or 5. CONCLUSION: Our results indicate that endovascular detachable coiling is a safe and effective treatment modality in paraclinoid aneurysms.

Aneurismas paraclínicos en el Hospital Dr. Hernán Henríquez Aravena de Temuco: experiencia de 16 años / Paraclinoidal aneurysms in the Dr. Hernán Henríquez Aravena Hospital in Temuco

Desde que se inicia la cirugía de aneurismas intracerebrales en el Hospital Dr. Hernán Henríquez Aravena de Temuco (año 1989) a la fecha, se han intervenido 8 por aneurismas paraclinoideos de la arteria carótida interna. Seis pacientes de sexo femenino y dos de sexo masculino, con un promedio de edad de 46.7 años al momento del ingreso. Siete debutaron con cuadro de hemorragia subaracnoídea, en 6 casos determinada por el aneurisma paraclinoideo y uno de otra localización. El restante paciente es diagnosticado a través de una tomografía parte del estudio de patología neoplásica del tracto digestivo. De la técnica utilizada destaca: Control de la arteria carótida cervical disecada previa al tiempo craneal, uso de drenaje espinal, abordaje pterional intradural, fresado de clinoides, disección del anillo distal y uso de clip quirúrgico según anatomía de la lesión. Los pacientes fueron intervenidos en un promedio de 10.12 días desde el inicio de la sintomatología o desde el hallazgo de la lesión en forma incidental. Buenos resultados quirúrgicos 87.5 por ciento y sobrevida promedio de 8 años a la fecha.

Since the beginning of surgery of intracraneal aneurysms in Temuco's Hospital, (1989) to our days, eightr patients has been operated because of an aneurysm situated at the paraclinoid segment of the internal carotid artery. Six of them were female and two were male, with a mean age of 46,7 years at the event. Seven patients consulted for a history of subarachnoid bleeding, six of them had a carotid - ophthalmic aneurysm. The diagnosis of the other patient was done by a tomographic control of malignant digestive tract pathology. All patients were approached by fronto-pterional side of the skull, previously doing a cervical incision at the same side of the aneurysm, to expose the primitive and internal carotid artery, intradural access and spinal drainage. Anterior clinoid process was extirpated and distal ring was dissected before clipping the aneurysm. The use of surgical clips was according to the anatomy of the lesion. The patient was operated in an average of 10 days since the beginning of the symptoms or since the casual discovery of the aneurysm. Good surgical prognosis in 87.5 percent and survival mean 8 days.

Determination of Aneurysmal Location with 3 Dimension-Computed Tomographic Angiography in the Microsurgery of Paraclinoid Aneurysms

OBJECTIVE: Determining the location of paraclinoid aneurysms for microsurgery is important for selecting treatment options, especially when deciding on the release of the dural ring in direct clipping. We examined the reliability of using the optic strut as an anatomical landmark for evaluating the location of paraclinoid aneurysms. METHODS: Cadaveric dissection was performed to establish the relationship of the optic strut to the dural ring. Results from these anatomic studies were compared with the three-demensional computed tomographic angiographic (3D-CTA) findings of nine patients with ten paraclinoid aneurysms between May 2004 and October 2005. These, 3D-CTA results were then compared with intraoperative findings. RESULTS: The inferior boundary of the optic strut accurately localized the point at the proximal dural ring in cadaveric study. The optic strut and its relationship to the aneurysms was well observed on the multiplanar reformats of 3D-CTA. During microsurgery, nine of ten aneurysms were verified to arise from distal to the upper surface of the optic strut. Two aneurysms that had arisen between the inferior and superior boundary of the optic strut were observed to lie within the carotid cave. One aneurysm which had arisen at the inferior boundary of the optic strut and directed inferiorly was observed to lie within the cavernous sinus just after the release of the proximal ring. CONCLUSION: The optic strut, as identified with multiplanar reformats of 3D-CTA, provided a reliable anatomic landmark for the proximal rings and an important information about the location of aneurysms around the anterior clinoid process (ACP). Therefore, 3D-CTA and the optic strut could become an invaluable tool and a landmark in the assessment of the location of paraclinoid aneurysms for microsurgery.

Progressive Visual Loss after Endovascular Coiling Treatment of a Large Paraclinoid Aneurysm / 대한뇌혈관외과학회지

Recently, favorable outcomes have been reported after the endovascular treatment of either ruptured or unruptured paraclinoid aneurysms. The complications specifically related to the endovascular treatment of paraclinoid aneurysms have also been reported in other studies. Visual symptoms related to the mass effects associated with giant paraclinoid aneurysm normally improve after coil embolization. However, these symptoms have also been reported to be exacerbated in some cases. The authors here report an unusual case of progressive visual loss occurring after endovascular coiling treatment in a case of a large paraclinoid aneurysm.

Surgical Approaches to Paraclinoid Aneurysms

OBJECTIVE: "Paraclinoid" aneurysms include those aneurysms arising from the internal carotid artery between the site of emergence of the carotid artery from the roof of the cavernous sinus and the origin of the posterior communicating artery. The authors reviewed and analysed the results of surgical approaches to paraclinoid aneurysms treated with transcranial surgery and endovascular surgery. METHODS: Between January 1998 and May 1999, 14 patients were treated surgically through ipsilateral and contralateral pterional approaches, and anterior interhemispheric approach, and endovascular surgery for paraclinoid aneurysms. All transcranial approaches were performed by same surgeon. The medical records, neuroimaging studies and videotapes which had been recorded operations were reviewed retrospectively. RESULTS: Twelve patients presented with subarachnoid hemorrhage and ICH. Nine of fourteen patients had multiple aneurysms. Thirteen cases were small and one was a large aneurysm. Six patients were treated through ipsilateral approaches, six contralateral pterional approaches, one anterior interhemispheric approach and one primarily by GDC embolization. All aneurysms treated through contralateral approaches were multiple aneurysms. Neck clipping was performed in 9(69.2%) of the thirteen aneurysms, wrapping in four cases, among them three cases were followed by GDC embolization. The surgical outcomes were: Glasgow Outcome Scale(GOS) I 71.4%, GOS II 21.4% and GOS V 7.1%. CONCLUSION: The surgical approaches to paraclinoid aneurysms should be chosen after careful anatomical evaluation of aneurysm and its neighboring structures. 3D-CT angiography and/or the raw data of MR angiography were useful. This study supports the usefulness of the contralateral approach to paraclinoid aneurysm associated with multiple aneurysms, unruptured and small aneurysms whose dome projecting medially, superiorly and dorsally. The determination of contralateral approach to small and medially projecting paraclinoid aneurysm may be stressful to operator, thus we believe anterior interhemispheric approach is better alternated. Also we recommend the endovascular surgery after reinforcement of aneurym neck and dome in the case with difficulty in clipping.