Paraclinoid Carotid Artery Aneurysms Research Articles

Impact of Anterior Clinoidectomy on Visual Function After Paraclinoid Carotid Artery Aneurysm Surgery: Power-Drill Versus No-Drill Technique

ABSTRACT BACKGROUND Few studies have attempted to make a direct comparison of the risk of visual impairment following extradural anterior clinoidectomy (EAC) with and without the use of a power drill. OBJECTIVE To evaluate postoperative visual outcomes between groups of patients with paraclinoid carotid artery aneurysms (PCAAs) who underwent surgical clipping with and without the use of a power drill during EAC. METHODS Between January 2010 and November 2019, 90 patients, 7 with ruptured and 83 with unruptured PCAAs, underwent clipping surgery at our hospital. The authors retrospectively analyzed postoperative visual complications from the medical records of these patients. RESULTS Among the 85 patients (excluding 3 patients with disturbance of consciousness caused by subarachnoid hemorrhage and 2 patients with preoperative visual disturbance) evaluated, EAC was conducted using a power drill in 64 patients and using a microrongeur in 21 patients. Permanent postoperative visual impairment developed in 14 (21.9%) patients in the drill group: 9 patients had ipsilateral lower nasal quadrant hemianopsia (ILNQH) and 5 patients had ipsilateral visual acuity reduction. Transient ILNQH developed in only 1 patient in the no-drill group. The incidence of permanent postoperative visual impairments was significantly lower in the no-drill group than in the drill group (P = .020). Seventeen (26.6%) patients developed transient oculomotor nerve palsy in the drill group, while no patients developed oculomotor nerve palsy in the no-drill group. CONCLUSION EAC using a microrongeur versus a power drill significantly improved visual outcomes after clipping surgery for PCAAs.

Preservation of the Optic Nerve during Surgery for Paraclinoid Carotid Artery Aneurysm

Preservation of the Optic Nerve during Surgery for Paraclinoid Carotid Artery Aneurysm

Flow Diversion for the Treatment of an Unruptured Paraclinoid Carotid Artery Aneurysm

Flow Diversion for the Treatment of an Unruptured Paraclinoid Carotid Artery Aneurysm

Flow Diversion for the Treatment of an Unruptured Paraclinoid Carotid Artery Aneurysm.

Abstract

Direct suction decompression and fenestrated clip reconstruction of complex paraclinoid carotid artery aneurysm: operative video and nuances of skull base technique.

Direct microsurgical clipping of complex paraclinoid carotid artery aneuryms remains a formidable technical challenge due to the auneurysm's deep location at the skull base, with adjacent bony anatomy, large size, wide neck, and complex neuroanatomical relationships. In this operative video atlas manuscript, the author demonstrates a step-by-step technique for microsurgical clip reconstruction of a large complex ventral paraclinoid carotid artery aneurysm, using a trapping and direct suction decompression strategy followed by multiple fenestrated clip reconstruction of the internal carotid artery (ICA) via a modified orbitozygomatic approach. The nuances of skull base techniques are illustrated including extradural optic nerve decompression, extradural anterior clinoidectomy, incision of the falciform ligament to untether the optic nerve, and release of the distal durai ring to obtain proximal control. Reconstruction of the ICA and preservation of the anterior choroidal artery were achieved with multiple fenestrated clips. Aneurysm obliteration and patency of flow through the ICA was confirmed on video indocyanine green and catheter angiography. Although novel endovascular strategies continue to evolve, these microsurgical skull base techniques should remain in the surgical armamentarium for treating these complex cranial base vascular lesions. The video can be found here: http://youtu.be/IPS6lslk1ds.

Role of superior hypophyseal artery in visual function impairment after paraclinoid carotid artery aneurysm surgery.

Although a number of studies have assessed the surgical treatment of paraclinoid-segment carotid artery aneurysms and resulting visual complications, less attention has been given to the results with respect to the superior hypophyseal artery (SHA). The authors evaluated the relationship between the aneurysm, the SHA itself, and postoperative visual function in patients with ruptured and unruptured SHA aneurysms. From January 1991 through December 2013, 181 patients with 190 paraclinoid carotid artery aneurysms received treatment at Shinshu University Hospital and its affiliated hospitals. The authors retrospectively analyzed charts, operative records, operative videos, and neuroimaging findings for these patients with or without postoperative visual complications. The authors identified 72 SHA aneurysms in 70 patients (mean age 58 years). Of 69 patients (1 patient died) evaluated, postoperative visual complications occurred in 9 (13.0%). Although the aneurysm size and SHA sacrifice did not lead to postoperative visual impairment, simultaneous treatment of bilateral aneurysms was a risk factor for postoperative visual complications. Unilateral SHA impairment may be safe (i.e., it may not induce ischemia of the optic pathway) for many, but not all, patients with SHA aneurysm.

Association of Intracranial Aneurysm and Loeys-Dietz Syndrome: Case Illustration, Management, and Literature Review

Loeys-Dietz syndrome (LDS) is a newly described connective tissue disease associated with aortic aneurysms. A strong association between LDS and intracranial aneurysms has not yet been documented in the literature. We present the first detailed report of an intracranial aneurysm finding in an LDS patient. The patient is a 20-year-old female recently diagnosed with LDS and found to harbor 2 incidental intracranial aneurysms on a screening magnetic resonance angiography: a 3-mm right carotid ophthalmic aneurysm and an 8-mm partially fusiform paraclinoid carotid artery aneurysm. A standard left pterional craniotomy was performed. Intraoperative adenosine was used instead of temporary clipping because her vessels were extremely friable. After reconstruction, an intraoperative indocyanine green angiogram was obtained, confirming complete aneurysmal obliteration and internal carotid artery patency. This is the first detailed report of a clear association between intracranial aneurysms and LDS. An association between LDS and intracranial aneurysms, if substantiated in a larger study, has implications for aneurysm screening in this population. Such an association may shed light on mechanisms of aneurysm formation, growth, and rupture.

DIRECT IMAGING OF THE DISTAL DURAL RING AND PARACLINOID INTERNAL CAROTID ARTERY ANEURYSMS WITH HIGH-RESOLUTION T2 TURBO-SPIN ECHO TECHNIQUE AT 3-T MAGNETIC RESONANCE IMAGING

To evaluate the feasibility of the direct visualization of the distal dural ring (DDR) and adjacent anatomic structures in patients with paraclinoid internal carotid artery aneurysms at 3-T magnetic resonance imaging (MRI). Six consecutive patients (1 man, 5 women; mean age, 45.5 years; age range, 34-51 years) who underwent a 3-T MRI examination for the evaluation of 7 paraclinoid carotid artery aneurysms were reviewed retrospectively. MRI scans were acquired using a T2 turbo-spin echo sequence with 2-mm thickness without gap on the coronal plane perpendicular to the diaphragma sellae. Identifications of the DDR, adjacent regional anatomic landmarks, and paraclinoid aneurysms were analyzed. The locations of the paraclinoid aneurysms were categorized into intradural (aneurysm neck and sac located above the DDR), transdural (aneurysm neck or sac were straddling the DDR), and extradural (aneurysm neck and sac located below the DDR). Interstudy agreement between computed tomographic angiography and 3-T MRI for the anatomic location of the paraclinoid aneurysms was assessed in 6 patients who underwent both examinations. In all cases, the DDR was clearly identified and the relationship between the DDR and the paraclinoid aneurysm was successfully determined on 3-T MRI. The aneurysm locations determined with 3-T MRI were 4 intradural and 3 extradural. A comparison between computed tomographic angiography and 3-T MRI revealed discordant anatomic locations in 3 aneurysms (3 of 6, 50%). Direct visualization of the DDR as well as precise evaluation of paraclinoid aneurysm location with high-resolution 3-T MRI is possible. This study shows that high-resolution 3-T MRI is an important means to determine the appropriate management for patients with paraclinoid aneurysms.

Retrograde suction decompression of giant paraclinoid aneurysms using a No. 7 French balloon–containing guide catheter

The treatment of large and giant paraclinoid carotid artery (CA) aneurysms often requires the use of suction decompression for safe and effective occlusion. Both open and endovascular suction decompression techniques have been described previously. In this article the authors describe a revised endovascular suction decompression technique that provides several advantages in the treatment of large and giant paraclinoid and CA aneurysms. A 51-year-old woman presented with a relatively brief history of progressive visual loss in the right eye, nonspecific headache, and an afferent pupillary defect. After angiography studies had been obtained, it was determined that she had a giant right paraclinoid internal CA aneurysm with a dome size of approximately 26 mm on the right and a neck diameter of 10 mm. A modified technique was performed in which suction decompression was used. With the aid of a No. 7 French Concentric balloon guide catheter (Concentric Medical, Inc., Mountain View, CA) and application of a temporary clip distal to the aneurysm, the aneurysm was trapped and decompressed using retrograde suction through the guide catheter when the balloon was inflated. After satisfactory placement of three permanent clips, an intraoperative angiogram obtained through the same guide catheter confirmed CA patency. The aneurysm was then punctured and aspirated, ensuring complete occlusion of the aneurysm sac and reconstruction of the parent vessel. The patient made an excellent recovery and did not suffer any complications. She did not experience worsening in her vision. This technical modification to endovascular suction decompression allows several potential advantages, including higher volume decompression and the ability to deliver endovascular devices to distal arterial locations.

MRI location of the distal dural ring plane: anatomoradiological study and application to paraclinoid carotid artery aneurysms

The distal dural ring plane (DDRP) separates the intradural from the extradural paraclinoid internal carotid artery. The purpose of this study was to evaluate its position with MR imaging. The protocol used a T2-weighted sequence in two orthogonal planes: diaphragmatic (DIA-P) and carotid (CAR-P). The DDRP passes through four anatomoradiological reference points (RefP). We developed on a cadaveric model a correlation method supported by correlation lines and angles (CA) projecting the RefP toward the DDRP. RefP were correlated to the DDRP in 65-84% of cases in the DIA-P and 60-76% of cases in the CAR-P. CA were identified and correlated to the DDRP, respectively, in 87% and 60% of cases in the DIA-P, and 60% and 51% of cases in the CAR-P (failure often related to a lack of visibility of just one RefP). A higher tissular contrast in living subjects allowed the identification of CA in 90% and 80% of cases, respectively, in the DIA-P and the CAR-P. We propose that CA, when identified, should be considered as an approximation of the inferior radiological limit of the DDRP curve. In difficult angiographical cases, this MRI protocol could help to locate paraclinoid aneurysms on both sides of the cavernous sinus roof.

Temporary Aneurysm Orifice Balloon Occlusion as an Alternative to Retrograde Suction Decompression for Giant Paraclinoid Internal Carotid Artery Aneurysms: Technical Note

Giant paraclinoid carotid artery aneurysms frequently require the temporary interruption of local circulation to facilitate safe clip occlusion. Owing to the brisk retrograde blood flow through the ophthalmic artery and cavernous branches, the simple trapping of the aneurysm by cervical internal carotid artery clamping and intracranial distal clipping may not adequately soften the lesion. Retrograde suction decompression aspiration of this collateral supply by a catheter introduced into the cervical internal carotid artery is a popular method to achieve aneurysm deflation. With a large collateral supply, the method is not effective enough. The advent of relatively long and maneuverable soft balloons allows temporary occlusion of the aneurysm orifice. We applied this method in two instances of giant carotid ophthalmic aneurysms. In both instances, a 15- to 20-mm-long and 4-mm-wide occlusion balloon was inserted in the internal carotid artery at the level of the aneurysm before craniotomy. After craniotomy and dissection of the aneurysm neck, the balloon was inflated under intraoperative angiographic control. The aneurysm became soft enough in both cases without tapping and aspiration to allow safe clip occlusion. In the first case, the postoperative course was uneventful and visual acuity improved. A known additional infraclinoid part of the aneurysm was eliminated endovascularly 5 months later using balloon-protected injection of vinyl alcohol copolymer (Onyx; Micro Therapeutics, Inc., Irvine, CA). In the second case, a postoperative symptomatic vasospasm developed 15 hours after surgery. Hypertensive therapy resulted in the disappearance of symptoms and an otherwise uneventful course with improvement of vision. This preliminary experience suggests that this new method is a feasible alternative to retrograde suction decompression.

内頚動脈硬膜輪近傍動脈りゅうの手術成績

内頚動脈硬膜輪近傍動脈りゅうの手術成績

鞍上部頭蓋咽頭腫に両側内頸動脈傍前床突起部動脈瘤を合併した1例

鞍上部頭蓋咽頭腫に両側内頸動脈傍前床突起部動脈瘤を合併した1例

Radiometric analysis of paraclinoid carotid artery aneurysms.

Classification of paraclinoid carotid artery (CA) aneurysms based on their associated branching arteries has been confusing because superior hypophyseal arteries (SHAs) are too fine to appear opacified on cerebral angiograms. The authors performed a retrospective radiometric analysis of surgically treated paraclinoid aneurysms to elucidate their angiographic and anatomical characteristics. A retrospective analysis was made of 85 intradural paraclinoid aneurysms in which the presence or absence of branching arteries had been determined at the time of surgical clipping. The lesions were classified as supraclinoid, clinoid, and infraclinoid aneurysms based on their relation to the anterior clinoid process on lateral angiograms of the CA. The direction of the aneurysms were measured according to angles formed between the medial portion of the horizontal line crossing the aneurysm sac and the center of the aneurysm neck on anteroposterior angiograms. Branching arteries were associated with 68 aneurysms, of which 28 were ophthalmic artery (OphA) lesions (32.9%) and 40 were SHA ones (47.1%); associated branching arteries were absent in 17 aneurysms (20%). Twenty-five aneurysms (29.4%) were located at the supraclinoidal level, 46 (54.1%) at the clinoidal, and 14 (16.5%) at the infraclinoidal. The majority of aneurysms identified at the supraclinoidal level were OphA lesions (44%) or those unassociated with branching arteries (48%), with mean directions of 57 degrees or 67 degrees, respectively. At the clinoidal level, the mean directions of aneurysms were 76 degrees in six lesions unassociated with branching arteries (13%), 43 degrees in 16 OphA lesions (35%), and -11 degrees in 24 SHA ones (52%). All aneurysms at the infraclinoidal level arose at the origin of the SHAs, with a mean direction of -29 degrees, and most of these were embedded in the carotid cave. Aneurysms arising from the SHA can be distinguished from those not located at an arterial division by cerebral angiography, because SHA lesions are usually located at the medial or inferomedial wall of the internal carotid artery at the clinoidal or infraclinoidal level. Their distribution correlates well with the reported distribution of SHA origins. The carotid cave aneurysm is a kind of SHA lesion that originates at the most proximal intradural CA.

Topographic anatomy of paraclinoid carotid artery aneurysms: usefulness of MR angiographic source images.

We evaluated the usefulness of magnetic resonance angiography (MRA) for showing the topography of paraclinoid carotid artery aneurysms in 27 patients with 30 paraclinoid aneurysms undergoing conventional angiography, three-dimensional time-of-flight MRA and surgery. The anatomy shown on the axial MRA source images was consistent with that found at surgery. The neck of the aneurysm could always be identified on the source images, while it could not be analysed exactly on conventional angiography in 3 cases (10%). The optic nerves, including those displaced by the aneurysm, were recognised in all patients. The anterior clinoid process was shown as a low-intensity rim or area contiguous with the cortical bone. The source images were of great value in understanding the topography of paraclinoid carotid artery aneurysms.

Ventral paraclinoid carotid aneurysms.

A series of 15 patients with 17 ventral paraclinoid carotid artery aneurysms is presented. With this type of aneurysm the neck is at or just distal to the level of the ophthalmic artery and proximal to the posterior communicating artery on the ventral surface of the carotid artery. There is a high incidence of female patients and multiple aneurysms. At surgery, the aneurysms are hidden by the anterior clinoid process and often have an intracavernous component. The neck of the aneurysm is usually intradural and can be clipped.