Treatment Of Paraclinoid Aneurysms Research Articles

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.

Direct Clipping of Paraclinoid Aneurysm in Conjunction with Extradural Anterior Clinoidectomy: Technical Nuance and Functional Outcome.

Objective Because of their anatomical features, treatment for paraclinoid aneurysms has remained to be challenging. Thus, the aim of this report is to prove the validity of our surgical method for unruptured paraclinoid aneurysms, together with surgical videos. Study Design Between August 2017 and November 2019, we were able to perform surgical clipping for 11 patients with unruptured paraclinoid aneurysm using a completely unified method. This study investigated the effect of surgery on multiple measures, including visual impairment, brain contusion, temporalis muscle atrophy, and multiple neurocognitive functions. Results Of the 67 unruptured aneurysms treated at our hospital, 17 were identified to be paraclinoid aneurysm, and 11 of them were treated by direct clipping using anterior clinoidectomy. Three were ophthalmic artery aneurysms, three were superior hypophyseal artery aneurysms, and five were anterior carotid wall aneurysms without branch projection. Only one patient had asymptomatic mild enlargement of the Marriott blind spots postoperatively. No brain contusion and temporalis muscle atrophy were observed in any cases. Only the Trail Making test (TMT) showed a significant worsening in the acute postoperative period: mean pre- and postoperative TMT scores were 59.1 ± 29.1 and 72.7 ± 37.3 for Part A ( p = 0.018) and 80.5 ± 35.5 and 93.8 ± 39.9 for Part B ( p = 0.030), respectively. However, it improved in the chronic phase. Conclusion We can conclude that our surgical method is safe and can be considered an acceptable treatment. Although surgical stress can cause temporary executive dysfunction shortly after surgery, this decline is temporary.

The Hybrid Neurosurgeon: The Japanese Experience.

In Japan, hybrid neurosurgeons who perform both open surgical clipping as well as endovascular embolization for the treatment of intracranial aneurysms are common. Although many Japanese neurosurgeons can perform surgical clipping of middle cerebral artery aneurysms or internal carotid artery-posterior communicating artery aneurysms and coil embolization of cerebral aneurysms using simple techniques-only a limited number of neurosurgeons are able to perform surgical clipping and endovascular procedures for anterior communicating artery aneurysms, paraclinoid, or posterior circulation aneurysms using both treatment modalities equally and safely. The senior author's personal experience of more than 500 cases each of surgical clipping and endovascular embolization over the past 25years included 110 cases of basilar tip aneurysms and 104 cases of paraclinoid internal carotid artery (ICA) aneurysms. The safety and efficacy of both treatments appears to be the same, while the durability of surgical clipping is superior to that of endovascular embolization. Among the 110 basilar tip aneurysms, 18 patients were treated by surgical clipping and 94 were treated by endovascular embolization. The initial results of endovascular therapy seemed to be better than those of surgical clipping, although the rate of retreatment was higher. Among the 104 cases of paraclinoid ICA aneurysm, 23 patients were treated by surgical clipping and 81 were treated by endovascular embolization. The results of both treatments seemed to be same, while surgical clipping had apparently good long-term durability. Over the past 15years, the frequency of surgical clipping for basilar tip aneurysms has decreased, and the procedure may eventually be abandoned for this type of aneurysm. However, surgical clipping still offers several advantages in the treatment of paraclinoid aneurysms. Hybrid neurosurgeons can make reasonable decisions concerning the choice of treatment for cerebral aneurysms, as they perform both treatments and understand the benefits and drawbacks of each modality.

Microsurgical treatment of paraclinoid aneurysms through Dolenc approach

Objective To investigate the surgical skills and clinical efficacy of microsurgical treatment of paraclinoid aneurysms via Dolenc approach. Methods The clinical data of 35 patients with paraclinoid aneurysms operated via Dolenc approach at Department of Neurosurgery, Shiyan Taihe Hospital from September 2014 to May 2018 were analyzed retrospectively. The 35 patients had 38 paraclinoid aneurysms, among which 13 were ruptured aneurysms (Hunt-Hess grade Ⅰ-Ⅲ) and 22 were unruptured.All patients underwent operation via pterional approach and paraclinoid aneurysms were exposed via Dolenc approach. In this study, 24 aneurysms were clipped directly and 11 were clipped and shaped. The intraoperative indocyanine green (ICG) angiography was performed to confirm the efficacy. Results Satisfactory results were achieved in 35 cases. All aneurysms were completely clipped which were confirmed by CT angiography or digital Subtraction angiography examination. Two patients with giant aneurysms developed cerebral infarction and mild hemiplegia on the contralateral side after surgery, which were improved in 1 following rehabilitation treatment. Three patients developed oculomotor nerve palsy which was improved after 3 months. Three patients with ruptured aneurysms had hydrocephalus within 2 months after operation and recovered following ventriculo-peritoneal shunt. All patients were followed up for a period of 1-43 months, with an average of 19±8 months. The GOS (Glasgow outcome scale) grade was Ⅴ in 29 cases, Ⅳ in 5 and Ⅲ in 1 at discharge. Conclusions The removal of anterior clinoid process in extradural space and dissociating distal dural ring via Dolenc approach is favorable for early control of parent artery, may provide a better surgical field for exposing and clipping aneurysms, and thus improve the safety and efficacy of surgical treatment of paraclinoid aneurysms. Key words: Intracranial aneurysm; Microsurgery; Paraclinoid; Dolenc approach

Microsurgical treatment of paraclinoid aneurysms: A report of 20 cases

Objective To investigate the microsurgical strategy and efficacy of paraclinoid aneurysms. Methods The clinical data of 20 patients with paraclinoid aneurysms were retrospectively reviewed who underwent microsurgical clipping from November 2015 to March 2017 at Neurosurgery Department of the First Affiliated Hospital of Chongqing Medical University. The operative methods included simple clipping and clipping of aneurismal neck and parent artery reconstruction. After the operation, the aneurysm clipping was examined by CTA or DSA, and the Glasgow prognosis score (GOS) was used to evaluate the clinical effect. All patients were followed up by outpatient clinic or telephone, and the GOS scale was used to assess the patient's prognosis. Results All patients achieved satisfactory results. There was no aneurysm recurrence or rebleeding in this series detected by CTA or DSA. Only 1 case of unruptured aneurysm had a small residual neck after treatment. There was no death during the perioperative period. The GOS grade was Ⅴ in 13 cases, Ⅳ in 6 and Ⅲ in 1 at discharge. All patients were followed up for a period of 1-18 months, with an average of 10±6 months. The GOS grade was Ⅴ in 16 cases and Ⅳ in 4 cases. Conclusion Microsurgical clipping of paraclinoid aneurysm seems to be safe and feasible, which could have a favorable outcome. Key words: Intracranial aneurysm; Microsurgery; Treatment outcome

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.

Abstract WP80: Microsurgical Clipping of Ophthalmic Artery Aneurysms:Surgical Results and Visual Outcomes With 208 Aneurysms

Background: While most paraclinoid aneurysms can be clipped with excellent results, new visual deficits postoperatively are a concern. Meanwhile, new technology like flow diverters has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. Objective: The increasingly endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. Therefore, we aimed to define patient, visual, and aneurysm outcomes in the most common paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms. Methods: Results from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc), clinical characteristics and patient outcomes were recorded and analyzed. Results: Despite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of aneurysms, with patency of OphA preserved in 99.5%. Aneurysm recurrence rate was 3.1% and retreatment rate was 0%. Good outcomes (modified Rankin Scale score: 0-2) were observed in 96.2% of patients overall, and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 3.8% (8 patients), decreased visual acuity in 2.4% (5 patients), and monocular blindness in 4.3% (9 patients). Vision improved in 9 of 17 patients (52.9%) with preoperative deficits. Conclusion: The most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.

Microsurgical and Endovascular Treatments for Ruptured Paraclinoid Aneurysms.

The treatment of paraclinoid aneurysms can be challenging due to their relationship to the cavernous sinus, carotid siphon, and optic nerve. The goal of this retrospective analysis is to compare the efficacy and safety of microsurgical versus endovascular treatments for ruptured paraclinoid aneurysms. Medical records were reviewed to collect information about patient demographics, risk factors, diagnosis (the position and size of aneurysms), Hunt and Hess grade, and surgical method and outcomes, including modified Rankin Scale (mRS) at the time of discharge and 6 months later, complications, and death. In total, 15 and 6 patients were recruited into the microsurgery and endovascular groups, respectively. No difference was detected regarding age, sex, risk factors, and Hunt and Hess grade. Most patients had ophthalmic segment aneurysms (87% versus 83%; p = 1.000) and small aneurysms (< 10 mm, 67% versus 100%; p = 0.102). In the microsurgical group, five patients (33%) had large aneurysms (10-25 mm); three patients (20%) had multiple aneurysms (all p > 0.05 compared with the endovascular group). The occlusion rate at 6 months was 93% in the microsurgical group and 100% in the endovascular group (p > 0.05). No difference was found regarding mRS or the complication and mortality rates between the two groups (all p > 0.05). The occurrence of complications was not related to the location and size of aneurysms (all p > 0.05). Our retrospective analysis indicates that good clinical outcomes can be achieved with both microsurgical and endovascular approaches. But further prospective randomized multicenter studies are needed to provide more evidence for clinical practice.

Vision outcomes in patients with paraclinoid aneurysms treated with clipping, coiling, or flow diversion: a systematic review and meta-analysis.

OBJECTIVE Patients with paraclinoid aneurysms commonly present with visual impairment. They have traditionally been treated with clipping or coiling, but flow diversion (FD) has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, FD is hypothesized to reduce mass effect, which may decompress the optic nerve when treating patients with visually symptomatic paraclinoid aneurysms. The authors performed a meta-analysis to compare vision outcomes following clipping, coiling, or FD of paraclinoid aneurysms in patients who presented with visual impairment. METHODS A systematic literature review was performed using the PubMed and Web of Science databases. Studies published in English between 1980 and 2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or FD. Neuroophthalmological assessment was used when reported, but subjective patient reports or objective visual examination findings were also acceptable. RESULTS Thirty-nine studies that included a total of 2458 patients (520 of whom presented with visual symptoms) met the inclusion criteria, including 307 visually symptomatic cases treated with clipping (mean follow-up 26 months), 149 treated with coiling (mean follow-up 17 months), and 64 treated with FD (mean follow-up 11 months). Postoperative vision in these patients was classified as improved, unchanged, or worsened compared with preoperative vision. A pooled analysis showed preoperative visual symptoms in 38% (95% CI 28%-50%) of patients with paraclinoid aneurysms. The authors found that vision improved in 58% (95% CI 48%-68%) of patients after clipping, 49% (95% CI 38%-59%) after coiling, and 71% (95% CI 55%-84%) after FD. Vision worsened in 11% (95% CI 7%-17%) of patients after clipping, 9% (95% CI 2%-18%) after coiling, and 5% (95% CI 0%-20%) after FD. New visual deficits were found in patients with intact baseline vision at a rate of 1% (95% CI 0%-3%) for clipping, 0% (95% CI 0%-2%) for coiling, and 0% (95% CI 0%-2%) for FD. CONCLUSIONS To the authors' knowledge, this is the first meta-analysis to assess vision outcomes after treatment for paraclinoid aneurysms. The authors found that 38% of patients with these aneurysms presented with visual impairment. These data also demonstrated a high rate of visual improvement after FD without a significant difference in the rate of worsened vision or iatrogenic visual impairment compared with clipping and coiling. These findings suggest that FD is an effective option for treatment of visually symptomatic paraclinoid aneurysms.

Anterior clinoidectomy for the management of paraclinoid aneurysms

Objective To investigate the surgical skills and clinical efficacy of anterior clinoidectomy for the management of paraclinoid aneurysms. Methods The clinical data of 25 patients with paraclinoid aneurysm treated with anterior clinoidectomy from January 2010 to July 2014 were analyzed retrospectively. Of the 25 patients, 19 were females and 6 were males (mean age 51.4 years). Six patients had multiple intracranial aneurysms, 8 had ruptured aneurysms, and 17 had unruptured aneurysms. The size of paraclinoid aneurysms: 6 were less than 5 mm, 13 were 5 mm to 15 mm, and 6 were more than 15 mm. All the patients performed the removal of the anterior clinoid process in subdural space via pterional approach, 9 aneurysms were clipped directly, and 16 were clipped and shaped. Postoperative digital subtraction angiography (DSA) was performed and the Glasgow outcome scale (GOS) was used to evaluate the efficacy during the follow-up period. Results Postoperative DSA indicated that 2 patients had residual aneurysm necks, and 2 had parent artery stenosis. All patients were followed up for 1 to 51 months (mean 22.5 months). Ten patients had good prognosis (GOS 5), 13 had mild disability (GOS 4), and 2 had severe disability (GOS 3). Conclusion The removal of the anterior clinoid process, opening the superior wall of optic canal, and isolating the internal carotid artery of clinoid segment may provide better a surgical field for exposing and clipping aneurysms, and thus improve the safety and efficacy of surgical treatment of paraclinoid aneurysms. Key words: Intracranial aneurysm; Microsurgery; Ophihalmic artery

Endovascular treatment of paraclinoid aneurysms: modified classification based microcatheter shaping technique

Objective To develop a modified classification to guide microcatheter shaping in endovascular management for paraclinoid aneurysms and to evaluate the efficiency of this technique.Methods From January 2009 to December 2011,consecutive 126 patients with 142 saccular paraclinoid aneurysms were treated with endovascular embolization at our institute.Paraclinoid aneurysms were classified as Type Ⅰ (ophthalmic artery aneurysms) and Type Ⅱ (superior hypophyseal artery aneurysm).Each type was further divided into two subtypes according to their relative position to an imaginary bisector that separated the origin of ophthalmic artery and posterior communicating artery.Ⅰ a and Ⅱ a referred to aneurysms arising from ICA proximal to the bisector,and Ⅰ b and Ⅱb referred to those aneurysms arising distal to the bisector.Recommended shapes of microcatheter for each subtype of the aneurysins were Ⅰ astraight,Ⅰ b-S shaped,Ⅱ a-C shaped (＜ 90 °) and Ⅱ b-primary curve (≥ 90°).The maneuverability of microcatheters was evaluated with an arbitrary score system.Results Of the 142 aneurysms,56 (39.4％)aneurysms were Type Ⅰ,while 86 (60.6％) were Type Ⅱ.24 aneurysms (16.9％) were managed with coil embolization,and 118 (83.1％) with stent-assisted coiling technique.Immediate angiography demonstrated complete occlusion in 62 (43.7％),neck remnant occlusion in 47 (33.1％) and residual aneurysm occlusion in 33 (23.2％) aneurysms.The microcatheter maneuverability scores ranked as Ⅰ b ＞Ⅱ a ＞ Ⅰ a ＞ Ⅱ b.The maneuverability of microcatheters in Type Ⅰ b was the least satisfactory (P ＜ 0.01).Conclusions A modified classification system of paraclinoid aneurysms may be used to guide microcatheter shaping during endovascular treatment. Key words: Paraclinoid aneurysms ; Endovascular treatment; Classification; Microcatheter

126 Histopathological Assessment of Delayed Ipsilateral Parenchymal Hemorrhages After the Treatment of Paraclinoid Aneurysms with the Pipeline Embolization Device

126 Histopathological Assessment of Delayed Ipsilateral Parenchymal Hemorrhages After the Treatment of Paraclinoid Aneurysms with the Pipeline Embolization Device

Pulsatile Tinnitus as the Sole Manifestation of an Internal Carotid Artery Aneurysm Successfully Treated by Coil Embolization

Pulsatile tinnitus is tinnitus that coincides with the patient's heartbeat. It constitutes a small portion of all tinnitus, but it is often the first or sole manifestation of a serious disease in the nervous system. Aneurysm of the internal carotid artery is known as a rare cause of pulsatile tinnitus and, in the main, aneurysms of the petrous portion have been reported as a cause of pulsatile tinnitus. We present an interesting case of pulsatile tinnitus that was caused by a paraclinoid aneurysm in this report and discuss clinical features and treatment of paraclinoid aneurysm.

Usefulness of a Simplified Management Scheme for Paraclinoid Aneurysms Based on a Modified Classification

Background: Our objective was to set up a management-oriented classification for paraclinoid aneurysms, and then design and apply a simplified management scheme according to each group defined by this classification. Methods: Paraclinoid aneurysms were classified as group I (supraophthalmic artery), group II (ophthalmic artery) and group III (infraophthalmic artery) aneurysms intradurally. Between January 2005 and December 2006, 86 cases with 89 paraclinoid aneurysms were treated. There were 35 (40.2%) aneurysms in group I (20 in group Ia, 15 in group Ib), 32 (36.8%) in group II and 20 (23%) in group III. Results: In group I aneurysms, 20 (57.1%) were treated by clipping or/and wrapping, while 15 (42.9%) were managed by coiling. In group II aneurysms, 20 (62.5%) were treated by clipping and 12 (37.5%) by coiling. The contralateral approach was performed for 4 (6%) aneurysms in groups I and II. All 20 group III aneurysms were treated by coiling. The overall rate of permanent complications was 4.6%. The rate of complete occlusion was 92.5% in surgical cases and 55.6% in endovascular ones. The overall outcomes in the treatment of paraclinoid aneurysms were excellent (GOS = 5, 95.4%). Conclusion: Based on our modified classification of paraclinoid aneurysms, a simplified management scheme was designed and applied. For group I (supraophthalmic artery) and group II (ophthalmic artery) aneurysms, surgical clipping or/and wrapping should be the first choice of treatment, while for group III (infraophthalmic artery) aneurysms, endovascular coiling should be the best modality. Additionally, individualizing the treatment planning might contribute to better results.

傍前床突起内頸動脈瘤と視機能温存(&lt;特集&gt;脳神経機能温存)

傍前床突起内頸動脈瘤の定義は,報告者によって若干の相違があるが,通常は内頸動脈硬膜輪から後交通動脈分岐部までの内頸動脈から発生した動脈瘤と考えられる.動脈瘤が内側上方へ増大するにしたがい視神経を圧迫し,さまざまな程度の視力・視野障害が出現する.クリッピング術に際しては前床突起の削除が必要なことも多い.視機能温存のためには,術中視神経の圧迫や損傷に注意するとともに,眼動脈・上下垂体動脈の走行にも注意を払う必要がある.傍前床突起内頸動脈瘤における視神経障害の原因を検討し,視機能温存のための工夫について報告する.

701 Combined Surgical and Endovascular Outcome in the Treatment of Paraclinoid Aneurysms

701 Combined Surgical and Endovascular Outcome in the Treatment of Paraclinoid Aneurysms