Large Paraclinoid Aneurysms Research Articles

Mechanical thrombectomy for internal carotid artery occlusion beyond a large paraclinoid aneurysm

BackgroundWith the launch of mechanical thrombectomy (MT), the prognosis of patients with cerebral infarction associated with large-vessel occlusion has improved. However, good outcomes are still not achieved in a few patients because of technical difficulties.Case presentationA 79-year-old Japanese woman was admitted with sudden-onset left hemiplegia. Tissue plasminogen activator was administered and MT was performed for internal carotid artery occlusion distal to a large paraclinoid aneurysm. Some technical difficulties were unique, including contrast agent retention, difficulty in guiding the system, and avoidance of rupture of the aneurysm. Here, we discuss the technical issues and solutions of the MT procedure employed in this case.ConclusionsThe procedure used in flow-diverter devices should be referenced and a stent-retrieving into an aspiration catheter with proximal balloon technique may be the most appropriate method.

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"}]}

Application of hybrid surgery in the clipping of large complex paraclinoid aneurysms

Nine patients with large complex paraclinoid aneurysms were treated by hybrid surgery in the Second Affiliated Hospital of Zhejiang University between January 2016 and July 2021. Intraoperative angiography was conducted for real-time evaluation of the aneurysm and its clipping efficacy. A total of 8 aneurysms were clipped under temporary proximal control with balloon occlusion. Suction decompression was simultaneously applied in 2 of these cases. After surgery, 2 patients developed symptomatic cerebral infarction, 3 patients developed transient oculomotor nerve palsy, but no patients had vision deterioration. Postoperative follow-up showed that small neck residue occurred in 1 case, but with the rest of aneurysms were completely occluded without parent artery stenosis. Hybrid surgery was proved to be advantageous in real-time assessment of aneurysm morphology and clipping efficacy. Combination of temporary proximal balloon occlusion and suction decompression technique can help in reducing the difficulty of aneurysm exposure and remodeling, thereby improving the outcome and decreasing the complications.

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.

Retrograde Suction Decompression for Clipping of a Giant Ophthalmic Internal Carotid Artery Aneurysm: 2-Dimensional Operative Video.

Microsurgical clipping of large paraclinoid aneurysms is challenging because of the complex anatomy of the dural rings, lack of easy proximal control, and wide aneurysm necks. Proximal retrograde suction decompression, or the Dallas technique, can reduce aneurysm turgor and, with aspiration of the trapped cervical and supraclinoid internal carotid arteries (ICAs), can collapse the aneurysm to aid microsurgical clipping.1-5 A woman in her late 30s presented with decreased right-eye visual acuity. Informed written consent was obtained for microsurgical management and publication. Upon cervical exposure of the carotid bifurcation, we performed a standard pterional craniotomy, trans-sylvian exposure, and intradural anterior clinoidectomy. After burst suppression and cross-clamping of the carotid, we inserted an angiocatheter at the common carotid artery (CCA). Distal temporary clips were placed on the posterior communicating artery and C7 ICA. With the cervical ICA unclamped, retrograde suction was continuously applied to deflate the aneurysm. We applied 2 pairs of fenestrated-booster clips to the aneurysm dome and a fifth clip to the aneurysm neck. After restoration of flow, indocyanine green angiography and Doppler assessments were performed. The proximal clip was converted into a curved clip to optimize ICA flow. Postoperative angiography confirmed complete occlusion of the aneurysm. The patient was discharged on postoperative day 3, with stable visual acuity.6 This video demonstrates that retrograde suction decompression via the cervical CCA can be safely performed to facilitate clipping of complex paraclinoid ICA aneurysms. Comprehensive planning of temporary aneurysm trapping for suction decompression and permanent clip construct for aneurysm occlusion are needed for effective aneurysm repair.

Comparison of Pipeline Embolization and Coil Embolization for the Treatment of Large Unruptured Paraclinoid Aneurysms.

The efficacy of flow diversion (FD) in the treatment of paraclinoid aneurysms has been established. The pipeline embolization device (PED) is one of the most commonly used FD devices. Coil embolization is also useful for treating paraclinoid aneurysms. This study aimed to compare the efficacy and safety of PED treatment and coil embolization for large unruptured paraclinoid aneurysms. This was a single-center, retrospective study of large unruptured paraclinoid aneurysms treated endovascularly between 2009 and 2019 (coil embolization between 2009 and 2015, and PED between 2015 and 2019). Cases with a follow-up period of less than 1 year and recurrence after coil embolization were excluded. The treatment outcomes between coil embolization and PED were compared. We investigated 45 patients with 45 large unruptured paraclinoid aneurysms treated by endovascular surgery in our institution. Twenty-four patients were treated with coil embolization and 21 with PED. In the PED group, the device cost was significantly lower (2,770.4 ± 699.5 vs. 1941.2 ± 552.8 [1000 yen], P = 0.03), procedure duration was significantly shorter (155.4 ± 66.7 vs. 95.1 ± 35.4 min, P <0.01), and the numbers of re-treatments were lower than those in the coil embolization group (41.7 vs. 14.3%, P = 0.05). Both PED and coil embolization were effective and safe for large unruptured paraclinoid aneurysms, and their treatment results were similar. The PED is more beneficial because of its lower cost, shorter procedure duration, and fewer retreatments, and is therefore more useful for the treatment of large unruptured paraclinoid aneurysms.

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.

How I do it: proximal control in parkinson\u2019s triangle for a very large paraclinoid aneurysm

BackgroundParaclinoid aneurysms, especially when they are large, can be quite difficult to treat, both endovascularly and through microsurgical clip reconstruction. There are many possibilities to approach this region surgically, and most hinge on total or partial removal of the anterior clinoid process. Gaining proximal control may be a challenge when space is limited, which is why Parkinson’s triangle may be a viable alternative in some cases.MethodsWe describe in a stepwise fashion the steps used to reconstruct a very large paraclinoid aneurysm. We first attempted to gain proximal control in the carotid cave and later in Parkinson’s triangle because of limited manoeuvrability.ConclusionProximal control in Parkinson’s triangle can be a safe alternative when the post-clinoidal segment of the internal carotid artery (ICA) is short and working space is limited in paraclinoid aneurysm microsurgical clip reconstruction.

Clipping Surgery for Large ICA Paraclinoid Aneurysms and Pitfalls

Clipping Surgery for Large ICA Paraclinoid Aneurysms and Pitfalls

A case report of retrograde suction decompression of a large paraclinoid aneurysm

Surgical clipping of large Paraclinoidal IC (Internal carotid) aneurysm pose a great challenge as there are adhesions hindering exposure of aneurysm dome and parent artery . Obtaining adequate visualization of the aneurysm neck is very difficult in these aneurysms, also in the access of proximal control. There are many methods to obtain a proximal control in these aneurysms. Retrograde suction decompression provides adequate visualization of the aneurysm neck and its relation with the optic apparatus. Retrograde suction decompression can be done by many methods. The technique done via open catheterization of superior thyroid artery is readily accessible and provides adequate relaxation of the aneurysm dome enabling complete dissection of the aneurysm from the surrounding important neurovascular structures. In this report of a case of left Paraclinoidal ICA aneurysm which was clipped applying this method, we elaborate on the technique and discuss other methods available for proximal control in these difficult aneurysms.

再塞栓時のStent 留置に際し3D Printer が有用だった大型傍鞍部内頸動脈瘤の1 例

再塞栓時のStent 留置に際し3D Printer が有用だった大型傍鞍部内頸動脈瘤の1 例

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.

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

Endovascular Treatment of a Giant Dissecting Aneurysm in an Infant

Introduction The incidence of intracranial aneurysms in the pediatric population is low, and endovascular treatment is becoming a safe and minimally invasive treatment option. In the present study, the occurrence of special features of cerebral aneurysm in children, in comparison to adults, is also described. Case Report A 3-month-old female infant presented with progressive proptosis and divergent strabismus at the right eye, in addition to inconsolable crying. Cerebral resonance, angiotomography and angiography exams demonstrated angiodysplasia in the right internal carotid artery with two large paraclinoid dissecting aneurysms with wide neck. The right internal carotid artery was occluded with coils by endovascular approach, without detriment to the perfusion of the ipsilateral hemisphere and without neurological deficits. The patient achieved good recovery, and a late control angiotomography confirmed the exclusion of the aneurysms. Conclusion Parent artery sacrifice via endovascular approach is an effective therapeutic option, but a long-term follow-up is necessary to avoid recurrence and bleeding.

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.

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

Modified extradural temporopolar approach with suction decompression for clipping of large paraclinoid aneurysm: Technical note

Background:Surgical clipping of complicated large paraclinoid aneurysms are still challenging because strong adhesion of aneurysm itself may hinder the dissection of the perforators and the surrounding anatomical structures from the aneurysm dome.Methods:We describe 13 consecutive patients and the clipping of complicated, large-sized paraclinoid aneurysms using a modified extradural temporopolar approach combined with retrograde suction decompression and discuss its advantages and pitfalls.Results:Modified extradural temporopolar approach with suction decompression (SD) assistance was performed in all patients. There was no complication related to the surgical procedure. Postoperative outcome was good recovery in 7 patients, moderate disability in 4, and severe disability in 2 caused by severe subarachnoid hemorrhage. Favorable outcomes were achieved in 10 patients (84.6%).Conclusion:We recommend its less invasive, safe, and useful combined technique in the treatment of symptomatic paraclinoid aneurysms, which carry the risk of neurovascular injury caused by dissection from the aneurysm dome.

Modified extradural temporopolar approach with suction decompression for clipping of large paraclinoid aneurysm: Technical note

Background: Cardiovascular diseases (CVD) are considered major health and economic burdens throughout the world. This study was conducted to estimate the magnitude of three major CVD (hypertension, ischemic heart diseases (IHD) and stroke), their risk factors, prevention and, control plan. Methods: The study design was cross-sectional. Multi-stage random sampling technique was used at different schools in Benghazi, Libya. A sample of 1200 teachers was randomly selected. Three formats were used for data collection. These included a self-administered questionnaire, a standardized Rose CVD interview questionnaire, as well as a special form for collecting data on the following: anthropometric measurements, blood pressure, clinical examination, as well as results of laboratory findings, and ECG tracings. Results: The prevalence of hypertension and IHD were 15.1% and 2.7% respectively while no cases of stroke could be detected in the study-sample. The selected CVD were found to be independently predicted by age, gender, family history of hypertension, BMI, smoking index, fasting blood sugar level, and HDL (CI 95%). Conclusion: Risk factors for hypertension & IHD among schoolteachers in Benghazi, Libya included age, BMI, fasting blood sugar, gender, smoking index, HDL, & family history of hypertension. There is thus an urgent need for intensive health education interventions for this group. There is also a need to initiate an implementation of a national program for CVD risk factors assessment, as well as promotion of an overall healthy lifestyle for school teachers through the use of health education which should be directed to smoking health related problems.