Giant Paraclinoid Aneurysms Research Articles

Application of hybrid operating room in the surgical treatment for intracranial aneurysm

BackgroundIntracranial aneurysms are associated with a high mortality rate in the event of a rupture and significant morbidity during subsequent treatment. Hybrid treatment approaches for vascular diseases have been incorporated into modern operating rooms as guides for surgical interventions now. The current study evaluates the feasibility and effectiveness of hybrid operating room system and its application in the surgical treatment of intracranial aneurysms. AimsTo evaluate the feasibility and effectiveness of hybrid operating room system and its application in the surgical treatment for aneurysms. Methods76 patients with 84 intracranial aneurysms were surgically treated in Hybrid operating room with intraoperative angiography between March 2018 and March 2021. Aneurysm clipping was performed in 76 (94.7 %) cases; Aneurysm trapping with extracranial-intracranial (EC-IC) bypass in 4 (5.3 %) cases. Patient demographics, aneurysm size, location, Hunt and Hess score, were recorded. 69 (90.8 %) patients were followed up 6–12 months post operation. ResultsIntraoperative angiography demonstrated 5 (6.9%) unexpected aneurysm neck residuals leading to adjustment; 6 (8.3%) parent vessel stenosis in which 5 returned to normal after adjustment. Four giant paraclinoid aneurysms trapping with EC-IC bypass showed total successful vessel reconstruction and complete aneurysm exclusion (100%). The postoperative outcome was evaluated with the modified Rankin Scale (mRS). 53 (76.8%) patients showed good outcome (mRS 0), 11 (15.9%) showed mild neurological defect (mRS 1–2), 3 (4.3%) showed poor outcome (mRS 5), and 2 (2.9%) patients died (mRS 6, Hunt-Hess grade V before surgery). Conclusion: Hybrid operating room provides new concepts in the surgically treatment of intracranial aneurysms, especially valuable for the complex aneurysms. The combination of intraoperative imaging of angiography and clipping surgery may offer the opportunity of radical clipping and reduced complications for aneurysm patients.

How I do it: The microsurgical clipping of the giant paraclinoid aneurysm using the retrograde suction decompression technique.

Paraclinoid aneurysms account for 5.4% of all intracranial aneurysms. Giant aneurysms are found in 49% of these cases. The 5-year cumulative rupture risk is 40%. Microsurgical treatment of paraclinoid aneurysms is a complex challenge that requires a personalized approach. Extradural anterior clinoidectomy and optic canal unroofing were performed in addition to orbitopterional craniotomy. Falciform ligament and distal dural ring transection provided the internal carotid artery and optic nerve mobilization. Retrograde suction decompression was used to soften the aneurysm. Clip reconstruction was performed using tandem angled fenestration and parallel clipping techniques. Orbitopterional approach with extradural anterior clinoidectomy combined with retrograde suction decompression technique is a safe and effective modality for treatment of giant paraclinoid aneurysms.

Visualization balloon occlusion-assisted technique in the treatment of large or giant paraclinoid aneurysms: A study of 17 cases series.

Although balloon-assisted techniques are valuable in aneurysm clipping, repeated angiography and fluoroscopy are required to understand the location and shape of the balloon. This study investigated the value of visualization balloon occlusion-assisted techniques in aneurysm hybridization procedures. We propose a visualization balloon technique that injects methylene blue into the balloon, allowing it to be well visualized under a microscope without repeated angiography. This study retrospects the medical records of 17 large or giant paraclinoid aneurysms treated by a visualization balloon occlusion-assisted technique in a hybrid operating room. Intraoperative surgical techniques, postoperative complications, and immediate and long-term angiographic findings are highlighted. All 17 patients had safe and successful aneurysm clipping surgery with complete angiographic occlusion. Under the microscope, the balloon injected with methylene blue is visible through the arterial wall. The position and shape of the balloon can be monitored in real time without repeated angiography and fluoroscopic guidance. Two cases of intraoperative visualization balloon shift and slip into the aneurysm cavity were detected in time, and there were no cases of balloon misclipping or difficult removal. Of 17 patients, four patients (23.5%) experienced short-term complications, including pulmonary infection (11.8%), abducens nerve paralysis (5.9%), and thalamus hemorrhage (5.9%). The rate of vision recovery among patients with previous visual deficits was 70% (7 of 10 patients). The mean follow-up duration was 32.76 months. No aneurysms or neurological deficits recurred among all patients who completed the follow-up. Our study indicates that microsurgical clipping with the visualization balloon occlusion-assisted technique seems to be a safe and effective method for patients with large or giant paraclinoid aneurysms to reduce the surgical difficulty and simplify the operation process of microsurgical treatment alone.

Transcranial Approach to Invasive Giant Pituitary Adenoma: 2-Dimensional Operative Video.

“…not knowing just what was the correct procedure, whether to go at the gland from above or below” -Harvey Cushing, cited by Cohen-Gadol et al1 Large and invasive pituitary tumors can be aggressive with extensive parasellar involvement and brain compression.2 Nowadays, most pituitary adenomas with suprasellar extensions are approached through a nasal transsphenoidal route with an excellent result; endoscope is particularly helpful in the visualization of parasellar extensions. There are, however, some cases where parasellar extensions with critical neurovascular encasement are beyond the axis of transsphenoidal route despite the advantageous use of endoscopy. In such cases, radical surgical removal cannot be achieved with transnasal approach, and the risk of infarct and hemorrhage of the residual tumor is considerable. A cranial approach allows extradural and intradural microsurgical dissection of the tumor involving the internal carotid artery and its branches and permits radical resection of laterally extending tumor and total decompression of the optic pathways.2,3 It is also more efficacious in recurrent cases4 We demonstrate this technique in a 28-year-old man with a giant tumor extending into the left hemisphere and right cavernous sinus operated in 1999 when radical resection was achieved. The patient presented in 2002 with growth in the remnant tumor in the right cavernous sinus. The tumor was resected with neurological function preservation including ocular movements. The transcranial approach to the giant and invasive pituitary adenomas is a safe option in selected cases to deal with these defiant tumors.4,5 The patient consented to surgery and publication of his images. Image at 2:06 reused from Surgical Neurology, 50(6), Arnautović KI, Al-Mefty O, and Angtuaco E, A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms, p 17, ©1998, with permission from Elsevier Science Inc. Images at 2:17 and 2:27 reused with permission from Al-Mefty O, Operative Atlas of Meningiomas, Vol 1, ©LWW, 1998. Images at 2:43 reused with permission from Krisht and Tyndall, Pituitary Disorders: Comprehensive Management, Vol 1, ©LWW, 1999. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_v58ijph3"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

Surgical Presets of Ruptured Dermoid Cyst Resection: 2-Dimensional Operative Video.

Intracranial dermoid cyst is a benign expansive lesion typically affecting children and young adults. They become symptomatic by progressive enlargement of the cyst and spilling of its content. In such cases, recurrent aseptic meningitis is observed. When located in the suprasellar area, optic pathways are usually displaced and compressed, and visual symptoms are common, as well as seizures. The tumor capsule can be thick and very adherent to the anterior cerebral arteries and the small arterial perforators. Radical surgical resection, including the capsule, is the current mainstay of treatment.1-5 The cranio-orbital approach is considered as an excellent surgical access option. Vascular adhesions are associated with a considerable surgical risk to the circle of Willis and its small branches. Residual cyst or perioperative spilling of its content produces severe aseptic meningitis and vasospasm associated with postoperative complications and long-term recurrences.4 This article demonstrates the details of the surgical management of a ruptured suprasellar dermoid cyst in a 22-year-old man. The patient consented to the procedure and publication of images. Image at 2:23 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas, Vol 1, ©LWW, 1998. Illustration at 2:47 reprinted from Surgical Neurology, 50(6), Arnautovic et al, "A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms," p 17, ©1998, with permission from Elsevier.

The Utilization of the Cranio-Orbital Zygomatic Approach for the Resection of Juvenile Nasopharyngeal Angiofibroma: 2-Dimensional Operative Video.

Juvenile angiofibroma is a rare benign expansive lesion typically affecting young men. Surgery is the current mainstay of treatment. Because it is a very vascular lesion, preoperative transarterial embolization can decrease intraoperative bleeding.1,2 Transmaxillary or transpalatal approaches were used for totally extracranial lesions. Endonasal endoscopic resection became wildly used for radical excision with limited morbidity.2 In large lesions with intracranial extension and cavernous sinus involvement (Fisch type 4), purely anterior approaches (endoscopic or transmaxillary) can be associated with significant carotid artery and cranial nerves injuries and excessive hemorrhage from internal carotid artery supply that cannot be eliminated by preoperative embolization.3 Subtotal resection has been preconized in such cases, but tumor progression, cranial nerves and vision compromise, and major nasal postoperative bleeding could ensue. Radiotherapy of residual tumor has been associated with long-term complications, particularly given the young age of these patients.2 The cranio-orbital zygomatic approach provides an excellent exposure to the extensions into the middle fossa, anterior fossa, cavernous sinus, paranasal sinus, and infratemporal fossa components of large angiofibromas.4-6 It is particularly advantageous in the early interruption of the cavernous carotid feeders that are not amenable to safe embolization, rendering the tumor devascularized and bloodlessly resected. This article demonstrates the details and the advantages of this approach in a 13-year-old adolescent boy operated in 1997 for giant juvenile angiofibroma with extension in the middle fossa and the parasellar space with major vascularization from the cavernous carotid artery. The guardian consented to the procedure and publication of images. Image at 3:05 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998. Image at 3:25 from Arnautović KI, Al-Mefty O, Angtuaco E. A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms. Surg Neurol. 1998;50(6):504-520; © Elsevier, 1998. Used with permission. Image at 9:21 reprinted from Kempe LG and Krekorian EA,6 with permission from John Wiley and Sons, © 1969 The Triological Society.

Simpson Grade I Resection of Type II Clinoidal Meningioma Through Cranio-orbital Zygomatic Approach: 2-Dimensional Operative Video.

Clinoidal meningiomas have been considered as a separate entity with distinguishing clinical, radiological, and surgical considerations.1-2 Surgical mortality and morbidity associated with anterior clinoidal meningiomas has remained high in the past, with radical resection considered unattainable.3 However, the extent of surgical removal is clearly the most determining factor in tumor recurrence and progression. Clinoidal meningiomas have been classified into 3 types according to their origin from the dura surface of the anterior clinoid and subsequent arachnoidal rearrangement around the parasellar neurovascular structures.1 In type II, there is an arachnoidal plane that allows the tumor dissection from the encased carotid artery and its branches and the optic nerve. In this type, the involvement of the cavernous sinus is limited to the external wall, which can also be removed. Hence, these tumors are amenable to Simpson grade I resection (tumor, dura, and bone). Approaching through the multidirectional axis provided by the cranio-orbital zygomatic approach allows safe exposure of the tumor and vascular control.4-5 Proximal carotid control is obtained in the petrous carotid canal, the invaded anterior clinoid is removed by and large extradurally, and the Sylvian fissure is split wide open to establish dissecting planes with the middle cerebral artery branches. The optic canal is opened, and tumor extension is removed.6 The invaded outer wall of the cavernous sinus and superior orbital fissure is removed. We demonstrate this technique in a 48-yr-old patient who consented for surgery and publication of images. All images at 2:27, center and right images at 2:46, and all images at 2:58, reused with permission from LWW, from Al-Mefty, Operative Atlas of Meningiomas. Left image at 2:46 reprinted from Surg Neurol, Vol 60/issue 6, Arnautović KI, Al-Mefty O, Angtuaco E, A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms, pp. 504-520, Copyright 1998, with permission from Elsevier. Image at 8:21 reprinted from Al-Mefty,1 Clinoidal meningiomas, by permission from JNSPG.

Early and midterm results of treatment of giant internal carotid artery paraclinoid aneurysms with trapping and flow diverters.

Flow diverter devices (FDD) carry risks of postoperative complications when treating aneurysms with wide necks, stenosis, and severe tortuosity of the parent vessel. In this study, we evaluated early and midterm results for the treatment of giant paraclinoid aneurysms managed by trapping and endovascular deployment of FDD. Medical records were analyzed for patients with giant paraclinoid aneurysms treated between July 2008 and December 2017 at National Centre for Neurosurgery with either a flow diverter or by trapping the aneurysm with or without extracranial-intracranial (EC-IC) bypass surgery. We recorded age, sex, clinical presentation, treatment modality, morbidity, and mortality. Clinical outcomes were assessed using a modified Rankin scale (mRS). Among 29 consecutive patients, 13 were treated with FDD, and 16 patients were managed by trapping the aneurysm, where 7/16 cases had preliminary EC-IC bypass. Of 16 trapping patients, six were trapped endovascularly and ten were trapped surgically. During the follow-up period (mean 33months, range 6-96), total exclusion of the aneurysm from the circulation was observed 100% of aneurysms in the trapping group and 84.6% in the FDD group (P = 0.192). Early postoperative morbidity was observed in three (23%) cases in the FDD group, and four (25%) in trapping group (P = 0.525). The FDD group had one (7.7%) fatal complication due to stent occlusion and severe ischemic stroke after threemonths postoperatively, despite appropriate antiplatelet therapy. There were no mortalities in the trapping group (P = 0.149). The rate of mRS 0-2 did not differ significantly across groups at discharge (81.3% vs. 69.2%; P = 0.667), and all patients had mRS 0-2 at follow-up (P = 1.000). FDD deployment for giant paraclinoid aneurysms results in comparable angiographic and clinical outcomes to aneurysm trapping. Despite implementation of modern endovascular treatment methods, aneurysm trapping remains a valuable treatment option in carefully selected patients with giant paraclinoid aneurysms.

The 25th anniversary of the retrograde suction decompression technique (Dallas technique) for the surgical management of paraclinoid aneurysms: historical background, systematic review, and pooled analysis of the literature.

Paraclinoid internal carotid artery (ICA) aneurysms frequently require temporary occlusion to facilitate safe clipping. Brisk retrograde flow through the ophthalmic artery and cavernous ICA branches make simple trapping inadequate to soften the aneurysm. The retrograde suction decompression (RSD), or Dallas RSD, technique was described in 1990 in an attempt to overcome some of those treatment limitations. A frequent criticism of the RSD technique is an allegedly high risk of cervical ICA dissection. An endovascular modification was introduced in 1991 (endovascular RSD) but no studies have compared the 2 RSD variations. The authors performed a systematic review of MEDLINE/PubMed and Web of Science and identified all studies from 1990-2016 in which either Dallas RSD or endovascular RSD was used for treatment of paraclinoid aneurysms. A pooled analysis of the data was completed to identify important demographic and treatment-specific variables. The primary outcome measure was defined as successful aneurysm obliteration. Secondary outcome variables were divided into overall and RSD-specific morbidity and mortality rates. Twenty-six RSD studies met the inclusion criteria (525 patients, 78.9% female). The mean patient age was 53.5 years. Most aneurysms were unruptured (56.6%) and giant (49%). The most common presentations were subarachnoid hemorrhage (43.6%) and vision changes (25.3%). The aneurysm obliteration rate was 95%. The mean temporary occlusion time was 12.7 minutes. Transient or permanent morbidity was seen in 19.9% of the patients. The RSD-specific complication rate was low (1.3%). The overall mortality rate was 4.2%, with 2 deaths (0.4%) attributable to the RSD technique itself. Good or fair outcome were reported in 90.7% of the patients.Aneurysm obliteration rates were similar in the 2 subgroups (Dallas RSD 94.3%, endovascular RSD 96.3%, p = 0.33). Despite a higher frequency of complex (giant or ruptured) aneurysms, Dallas RSD was associated with lower RSD-related morbidity (0.6% vs 2.9%, p = 0.03), compared with the endovascular RSD subgroup. There was a trend toward higher mortality in the endovascular RSD subgroup (6.4% vs 3.1%, p = 0.08). The proportion of patients with poor neurological outcome at last follow-up was significantly higher in the endovascular RSD group (15.4% vs 7.2%, p < 0.01). The treatment of paraclinoid ICA aneurysms using the RSD technique is associated with high aneurysm obliteration rates, good long-term neurological outcome, and low RSD-related morbidity and mortality. Review of the RSD literature showed no evidence of a higher complication rate associated with the Dallas technique compared with similar endovascular methods. On a subgroup analysis of Dallas RSD and endovascular RSD, both groups achieved similar obliteration rates, but a lower RSD-related morbidity was seen in the Dallas technique subgroup. Twenty-five years after its initial publication, RSD remains a useful neurosurgical technique for the management of large and giant paraclinoid aneurysms.

Rupture of Intradural Giant Aneurysms: The Mode of Treatment, Anatomical, and Mechanical Factors.

Aneurysm rupture is often a fatal complication of giant intradural aneurysm (GIA) treatments. The purpose of this study was to review aneurysm rupture in GIA treatment. We performed a systematic review on aneurysm rupture related to GIA treatment. For each reported case, we collected the following information: aneurysm location, size and rupture status, the mode of treatment, timing of the hemorrhage, anatomical, and hemodynamic factors. We identified 56 aneurysm ruptures related to treatment in 38 published studies. Of the nine intraoperative ruptures, eight occurred during endovascular procedures and one in surgical treatment. Of the 47 delayed ruptures, 72.3% occurred within 2 weeks. The prognosis of intraoperative and delayed ruptures was poor, with 83.9% experiencing death. Of these aneurysms, 75% were initially unruptured. Of the delayed ruptured aneurysms, 21.3% had prior surgical treatment, 74.4% had prior endovascular treatment, and 4.3% had prior combined surgical and endovascular treatments. Vertebrobasilar artery (VBA) location was significantly associated with aneurysm rupture after treatment, occurring at 57.2%. Flow diverter (FD) treatment seemed to elevate the delayed rupture proportion of giant paraclinoid internal carotid artery (ICA) aneurysms from 22.0% to 42.9%. FD treatment did not lower the rupture risk of giant VBA aneurysms and the corresponding death rate. Intraoperative and delayed aneurysm ruptures were the most challenging in endovascular treatment of GIAs. Giant VBA aneurysm had the highest rupture risk after treatment. FD seemed to elevate the delayed rupture proportion of giant paraclinoid aneurysms.

Extracranial-intracranial bypass and aneurysm trapping for the treatment of large and giant paraclinoid carotid aneurysms

Objective To explore the methods and effects of extracranial-intracranial (EC-IC) bypass and aneurysm trapping for the treatment of large and giant paraclinoid aneurysms. Methods The clinical data of 12 patients with paraclinoid aneurysms were analyzed retrospectively. Those patients were admitted to Department of Neurosurgery, the First Affiliated Hospital of Soochow University between April 2014 and February 2018. There were totally 12 aneurysms in 12 patients, including 8 giant and 4 large aneurysms. There were 1 case of postoperative bleeding of aneurysm embolization and 1 case of thrombotic aneurysms and 1 case of blood blister-like aneurysm. All cases underwent EC-IC high flow bypass and trapping of the aneurysms. The outcomes were evaluated based on the Glasgow Outcome Scale (GOS). Results Intraoperative fluorescein angiography and ultrasound suggested bridge vascular patency. The assessment at discharge indicated a GOS of 4-5 (good outcome) in 9 cases and GOS of 2-3 (severe disability) in 3 cases. There was no death. One was lost to follow-up. Eleven patients were followed up for 6-46 months post operation. The GOS of 4-5 (good outcome) was reported in 10 cases and 2 (severe disability) in 1 case. The bridge vascular patency was revealed in 10 cases. Conclusion The operation of EC-IC bypass combined with aneurysm trapping seems effective in the treatment of large and giant paraclinoid aneurysms. Key words: Intracranial aneurysm; Carotid artery, internal; Treatment outcome; Prognosis; Cerebral revascularization

Endoscopic Endonasal Clipping of Anterior Circulation Aneurysm: Surgical Techniques and Results

Endoscopic endonasal clipping of intracranial aneurysms may use microsurgical techniques as an alternative to the transcranial approach. Here we report a series of patients who underwent microsurgical clipping of anterior circulation aneurysms via an endoscopic endonasal approach (EEA). This retrospective chart review included all the patients who underwent standard binostril EEA for aneurysm clipping. Surgical outcomes and complications are noted. The rationality and limitations of this procedure are discussed. Seven patients with 12 aneurysms of the anterior circulation underwent EEA for clipping. These 12 aneurysms consisted of 5 anterior communicating artery (AComA) aneurysms, 4 paraclinoid aneurysms, 1 ophthalmic artery aneurysm, and 2 aneurysm located in the cavernous segment of internal carotid artery (ICA). Nine of the 12 aneurysms were successfully clipped. One giant paraclinoid aneurysm could not be clipped during operation and was coiled in second endovascular stage. The 2 aneurysms located in the cavernous segment of ICA were not clipped intentionally in a single-stage procedure, after weighing the surgical benefit against the difficulty of surgical exposure and feasibility. The proximal control of ICA was achieved in all cases. There was no death, no cerebrospinal fluid leak, or other complications. All patients recovered completely. EEA can provide direct access for microsurgical clipping of strictly selected anterior circulation aneurysms. All the principles of cerebrovascular surgery must be followed. These procedures require a long learning curve. Only teams with adequate experience in microvascular and endoscopic skull base surgeries should attempt this approach for treating aneurysms.

Entire Orifice Blocking-Assisted Microsurgical Treatment: Clipping of Intracranial Giant Wide-Neck Paraclinoid Aneurysms.

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.

Outcome Analysis of the Flow Diversion with Pipeline Embolization Device for the Surgical Treatment of Unruptured Large and Giant Paraclinoid Carotid Aneurysms

Background: Both the high frequency of recurrence of large or giant paraclinoid aneurysms (PA) of the internal carotid artery and the occurrence of intra- and postoperative complications, leading to unsatisfactory results of surgical treatment of this group of patients, make the stated problem urgent. Flow-diverter embolization devices are actively used in many large international neurosurgical centers for the treatment of cerebral aneurysms of different morphology, size, and localization. Currently, there are very few reports on the effectiveness of the use of flow diverting stents in the surgical treatment of large and giant PA of the internal carotid artery. The results of these studies are controversial and largely contradictory. Aim: Outcome analysis of the use of Pipeline embolization device (PED) for the surgical treatment of large and giant carotid PA. Methods: The study enrolled 37 patients (25 women, 12 men; mean age 51.7±10.7 years) who were divided into those treated with the PED alone versus those treated with the PED and concurrent coil embolization. The average follow-up period was 19.7±3.8 months. Results: In 56.7% of cases, PA caused the development of an insignificant neurological deficit (Modified Rankin Scale 1−2). In 18.9% of patients, PA provoked a gross neurologic deficit (MRS 3−5). 24.3% of patients with PA did not have any clinical-neurological manifestations. After the surgery, neurologic status improved in 32.4% of patients, remained the same — in 45.9% of cases, and the degree of neurologic deficit increased in 21.6%. PED procedure was performed in 70.2% of patients. In 29.7% of cases, the dislocation of large or giant PA of the internal carotid artery from the systemic blood stream was performed using PED and concurrent coil embolization. At the indicated period of patient observation, complete occlusion of large and giant carotid PA was achieved in 75.6% of cases, almost complete and partial occlusion — in 24.3%. The incidence of thromboembolic and hemorrhagic complications was 10.8% and 8.1%, respectively. Mortality rate among patients was 2.7%. Conclusions: The use of PED is an effective method for occluding large or giant PA of the internal carotid artery. Nevertheless, this method of endovascular treatment of PA is associated with a high complication incidence.

Improvement in venous-phase delay after superficial temporal artery to middle cerebral artery bypass

The utility of superficial temporal artery to middle cerebral artery (STA-MCA) bypass before therapeutic internal carotid artery (ICA) occlusion is unclear. A 65-year-old woman with a symptomatic giant left paraclinoid ICA aneurysm underwent endovascular ICA occlusion following STA-MCA double bypass. Preoperative balloon test occlusion (BTO) demonstrated a venous-phase delay of 1.5 s. Only focal improvement in the venous-phase delay was observed immediately after treatment, but three-week postoperative angiography showed remarkable improvement of 0.5 s. To our knowledge, this is the first known case that demonstrates the effect of STA-MCA bypass on postoperative improvement in venous-phase delay.

Surgical clipping for large and giant unruptured paraclinoid aneurysms in hybrid operation theater

Objective To evaluate the clinical value and outcomes of surgical clipping for large and giant unruptured paraclinoid aneurysms. Methods A retrospective analysis was conducted on 8 patients (11 aneurysms) who underwent aneurysm clipping assisted with balloon occlusion in hybrid operation theatre at Neurosurgery Department of Xuanwu Hospital, Capital Medical University, from January 2014 to March 2017. All patients were females whose average age was 54.9±5.7 years. Results Among 11 aneurysms in this series, a total of 9 aneurysms were treated and included 8 large or giant paraclinoid aneurysms and 1 carotid cave aneurysm. Intraoperative radiography demonstrated that all 9 aneurysms were successfully obliterated, 1 patient developed occlusion of parent artery and 1 had severe stenosis of parent artery. Three patients encountered ischemic events postoperatively. The assessment at discharge indicated a Glasgow Outcome Score (GOS) of 5 in 5 patients, 4 in 1 case and 3 in 2 cases. At the follow-up which was conducted 1.5-39.5 [average: 10.7 (P25: 3.2, P75: 32.3)] months post operation, a GOS of 5 was reported 7 patients and 4 in 1 case. Vision acuity was improved in 7 patients and remained stable in 1 case. Conclusion Hybrid surgery seems to be able to facilitate clipping of large and giant unruptured paraclinoid aneurysms, but more studies are needed for exploration of proper interventional devices and methods. Key words: Intracranial aneurysm; Carotid artery, internal; Paraclinoid; Hybrid operation; Balloon occlusion; Surgical clipping

Microsurgical treatment of large and giant paraclinoid carotid aneurysms using a revised endovascular suction decompression technique with Invatec Mo.Ma device

Endovascular retrograde suction decompression (RSD) with balloon occlusion of the internal carotid artery is helpful to facilitate clipping large and giant paraclinoid carotid aneurysms. The authors reported a revised endovascular technique without internal carotid access using Mo.Ma device and analyzed its feasibility. In the series, 15 consecutive patients harboring 15 large and giant paraclinoid carotid aneurysms were clipped with assistance of this revised RSD technique. The technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated. Technical success was achieved in 14 patients with aneurysm neck clipping and internal carotid artery (ICA) patent. No complication related to this endovascular technique occurred. At follow-up (mean time 15.3months), the modified Rankin Scale score was excellent in 11 patients, good in two patients and poor in one patient. Their preliminary experience indicates that revised retrograde suction decompression technique with Mo.Ma device seems effective and safe in the surgical treatment of large and giant paraclinoid ICA aneurysms.

Retrograde Suction Decompression Through Direct Puncture of the Common Carotid Artery for Paraclinoid Aneurysm.

Surgical clipping of paraclinoid aneurysm can be very difficult because strong adhesions may hinder the dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience with using retrograde suction decompression during the clipping of paraclinoid aneurysms and discuss the relative advantages and pitfalls. This study included 23 patients with large and giant paraclinoid aneurysms who underwent surgical treatment consisting of direct clipping with suction decompression between March 2004 and August 2014. Direct puncture of the common carotid artery (CCA) was performed with a 20-gauge needle. The aneurysm was temporarily trapped by clamping of the CCA and external carotid artery (ECA), followed by temporary clipping of the intracranial internal carotid artery (ICA) distal to the aneurysm neck. Blood was then gently aspirated through a catheter introduced into the cervical ICA, resulting in collapse of the aneurysm. Therefore, safe aneurysm dissection was feasible during interruption of the blood flow, which could be maintained for up to 5 min. This procedure was repeated until dissection and clipping of the aneurysm were completed. Seven patients were admitted with SAH, 11 with asymptomatic unruptured aneurysm, and 5 with symptomatic unruptured aneurysm. The aneurysms were located on the paraclinoidal segment of the ICA in 15 cases, on the ICA-posterior communicating artery (PComA) in 6, at the ICA bifurcation in 1, and on the anterior wall of the ICA in 1. None of them suffered complications related to the CCA puncture. Surgical outcome was good recovery in 13 patients, moderate disability in 4, severe disability in 4, and vegetative state in 1. Retrograde suction decompression through direct puncture of the common carotid artery is a useful adjunct technique for the clipping of paraclinoid ICA aneurysms.

Visual outcomes of endovascular and microsurgical treatment for large or giant paraclinoid aneurysms.

The optimal treatment for large or giant paraclinoid aneurysms is still controversial. The present study evaluated the results of endovascular coiling and microsurgical clipping with special reference to visual outcomes. The clinical data and treatment outcomes of 39 cases of large (>15 mm) paraclinoid aneurysms were retrospectively reviewed. Presenting symptoms were subarachnoid hemorrhage in 16 aneurysms and visual impairment in 18. Twenty-one aneurysms were treated by endovascular therapy and 18 were treated by direct surgery. Maximal aneurysm diameter ≥25 mm and preoperative visual acuity <20/100 were significantly related to poor visual outcome in univariate analysis. However, preoperative visual acuity was the only significant prognostic factor in multivariate analysis (odds ratio [OR] 0.12, 95 % confidence interval [CI] 0.01-0.95, p = 0.04). Although patients treated with endovascular coiling tended to have more favorable outcome than those with surgical clipping, adjustment for other confounding factors reduced the OR of favorable outcome following each treatment modality to nearly one (OR 1.14, 95 % CI 0.17-7.46, p = 0.89). Deteriorations in the visual field showed different patterns: upper visual field deficit after endovascular coiling, and inferior nasal quadrantanopia after microsurgical clipping. Preoperative visual acuity was the only independent predictor of visual outcome in patients with large paraclinoid aneurysms. Although adjusted visual outcomes with microsurgical clipping and endovascular coiling were almost the same, selection of the optimal treatment for each aneurysm is essential with recognition of the potential risks and mechanisms of visual impairment.

Editorial: Ophthalmic segment aneurysms

Very large and giant paraclinoid aneurysms are a therapeutic challenge. The goal of treatment is prevention of aneurysm growth/rupture and, in those patients with visual symptoms related to mass effect, stabilization and possible improvement of the visual deficits. Better understanding of the 3D relationships of the anterior clinoid/optic nerve/aneurysm–internal carotid artery (ICA) complex has resulted in good surgical outcomes being reported in several series. Traditional endovascular methods (coiling with or without the adjunct of balloon and stent assistance) provide an effective treatment for most small paraclinoid aneurysms with a very low complication rate.1 However, until the development of flow diverters, ICA-preserving endovascular solutions for very large and giant aneurysms were less than ideal with a very high recurrence rate. Carotid sacrifice is a valid option in many patients with very large and giant paraclinoid aneurysms, but concerns exist about the development of flow-related aneurysms and long-term effects. In their article, Mattingly and coworkers4 detail visual and clinical outcomes in a series of 17 patients (with clipped aneurysms) with challenging ophthalmic segment aneurysms. This report is an honest assessment of the results that particularly pertain to visual symptoms. Of the 14 patients presenting with visual symptoms, 79% experienced improvement in their vision at follow-up, while 21% experienced worsening in the ipsilateral eye. When visual acuity is considered, 53% of patients improved and 16% worsened. The authors used a modification of the suction-decompression technique and do a nice job in discussing the technical nuances. The value of this detailed study is to provide a benchmark (especially in relation to visual outcome) against which results of modern series can be evaluated. This is of special importance at a time when the development of flow diverters may represent a major paradigm shift and may soon become the treatment of choice for these challenging lesions.3,5 In the Pipeline for Uncoilable or Failed Aneurysms (PUFS) study, a detailed preand postoperative neuroophthalmological assessment was part of the study protocol. In the PUFS study, 17 patients had optic neuropathy (defined as a visual field deficit, decreased visual acuity, or an afferent pupillary defect) related to the aneurysm. Six months after treatment, 53% of the patients experienced improvement of their visual symptoms, 41% were stable, and only 1 patient (6%) experienced worsening.2 Thus, although not as good as the results reported in this series, it appears that visual outcomes after flow diversion are fairly close. (http://thejns.org/doi/abs/10.3171/2012.12.JNS121401)