Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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The Avoidance of Microsurgical Complications in the Extradural Anterior Clinoidectomy to Paraclinoid Aneurysms

  • Son, Hee-Eon (Department of Neurosurgery, School of Medicine, Eulji University) ;
  • Park, Moon-Sun (Department of Neurosurgery, School of Medicine, Eulji University) ;
  • Kim, Seong-Min (Department of Neurosurgery, School of Medicine, Eulji University) ;
  • Jung, Sung-Sam (Department of Neurosurgery, School of Medicine, Eulji University) ;
  • Park, Ki-Seok (Department of Neurosurgery, School of Medicine, Eulji University) ;
  • Chung, Seung-Young (Department of Neurosurgery, School of Medicine, Eulji University)
  • Received : 2009.10.28
  • Accepted : 2010.09.15
  • Published : 2010.09.28
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Abstract

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

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References

  1. Arnautovic KI, Al-Mefty O, Angtuaco E : A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms. Surg Neurol 50 : 504-518; discussion 504-518, 1998 https://doi.org/10.1016/S0090-3019(97)80415-6
  2. Avci E, Bademci G, Ozturk A : Microsurgical landmarks for safe removal of anterior clinoid process. Minim Invasive Neurosurg 48 : 268-272, 2005 https://doi.org/10.1055/s-2005-915595
  3. Batjer HH, Kopitnik TA, Giller CA, Samson DS : Surgery for paraclinoidal carotid artery aneurysms. J Neurosurg 80 : 650-658, 1994 https://doi.org/10.3171/jns.1994.80.4.0650
  4. Beretta F, Andaluz N, Zuccarello M : Aneurysms of the ophthalmic (C6) segment of the internal carotid artery : treatment options and strategies based on a clinical series. J Neurosurg Sci 48 : 149-156, 2004
  5. Boet R, Wong GK, Poon WS, Lam JM, Yu SC : Aneurysm recurrence after treatment of paraclinoid/ophthalmic segment aneurysms--a treatment- modality assessment. Acta Neurochir (Wien) 147 : 611-616; discussion 616, 2005 https://doi.org/10.1007/s00701-005-0524-4
  6. Cawley CM, Zipfel GJ, Day AL : Surgical treatment of paraclinoid and ophthalmic aneurysms. Neurosurg Clin N Am 9 : 765-783, 1998
  7. Chang HS, Joko M, Song JS, Ito K, Inoue T, Nakagawa H : Ultrasonic bone curettage for optic canal unroofing and anterior clinoidectomy. Technical note. J Neurosurg 104 : 621-624, 2006 https://doi.org/10.3171/jns.2006.104.4.621
  8. Coscarella E, Baskaya MK, Morcos JJ : An alternative extradural exposure to the anterior clinoid process : the superior orbital fissure as a surgical corridor. Neurosurgery 53 : 162-166; discussion 166-167, 2003 https://doi.org/10.1227/01.NEU.0000068866.22176.07
  9. De Jesus O, Sekhar LN, Riedel CJ : Clinoid and paraclinoid aneurysms : surgical anatomy, operative techniques, and outcome. Surg Neurol 51 : 477-487; discussion 487-488, 1999 https://doi.org/10.1016/S0090-3019(98)00137-2
  10. Dolenc VV : A combined epi- and subdural direct approach to carotidophthalmic artery aneurysms. J Neurosurg 62 : 667-672, 1985 https://doi.org/10.3171/jns.1985.62.5.0667
  11. Dolenc VV : A combined transorbital-transclinoid and transsylvian approach to carotid-ophthalmic aneurysms without retraction of the brain. Acta Neurochir Suppl 72 : 89-97, 1999
  12. Dolenc VV : Frontotemporal epidural approach to trigeminal neurinomas. Acta Neurochir (Wien) 130 : 55-65, 1994 https://doi.org/10.1007/BF01405503
  13. Drake CG, Vanderlinden RG, Amacher AL : Carotid-ophthalmic aneurysms. J Neurosurg 29 : 24-31, 1968 https://doi.org/10.3171/jns.1968.29.1.0024
  14. Fernandez Zubillaga A, Guglielmi G, Viñuela F, Duckwiler GR : Endovascular occlusion of intracranial aneurysms with electrically detachable coils : correlation of aneurysm neck size and treatment results. AJNR Am J Neuroradiol 15 : 815-820, 1994
  15. Fox JL : Microsurgical treatment of ventral (paraclinoid) internal carotid artery aneurysms. Neurosurgery 22 : 32-39, 1988
  16. Froelich SC, Aziz KM, Levine NB, Theodosopoulos PV, van Loveren HR, Keller JT : Refinement of the extradural anterior clinoidectomy : surgical anatomy of the orbitotemporal periosteal fold. Neurosurgery 61 : 179-185; discussion 185-186, 2007
  17. Gurian JH, Viñuela F, Guglielmi G, Gobin YP, Duckwiler GR : Endovascular embolization of superior hypophyseal artery aneurysms. Neurosurgery 39 : 1150-1154; discussion 1154-1156, 1996 https://doi.org/10.1097/00006123-199612000-00016
  18. Heros RC : Paraclinoid aneurysms. J Neurosurg 96 : 647-648, 2002 https://doi.org/10.3171/jns.2002.96.4.0647
  19. Hoh BL, Carter BS, Budzik RF, Putman CM, Ogilvy CS : Results after surgical and endovascular treatment of paraclinoid aneurysms by a combined neurovascular team. Neurosurgery 48 : 78-89; discussion 89-90, 2001
  20. Hope JK, Byrne JV, Molyneux AJ : Factors influencing successful angiographic occlusion of aneurysms treated by coil embolization. Am J Neuroradiol 20 : 391-399, 1999
  21. Jin SC, Kwon do H, Song Y, Kim HJ, Ahn JS, Kwun BD : Multimodal treatment for complex intracranial aneurysms : clinical research. J Korean Neurosurg Soc 44 : 314-319; discussion 314-319, 2008 https://doi.org/10.3340/jkns.2008.44.5.314
  22. Kattner KA, Bailes J, Fukushima T : Direct surgical management of large bulbous and giant aneurysms involving the paraclinoid segment of the internal carotid artery : report of 29 cases. Surg Neurol 49 : 471-480, 1998 https://doi.org/10.1016/S0090-3019(97)00374-1
  23. Krayenbühl N, Hafez A, Hernesniemi JA, Krisht AF : Taming the cavernous sinus : technique of hemostasis using fibrin glue. Neurosurgery 61 : E52; discussion E52, 2007 https://doi.org/10.1227/01.neu.0000289712.72555.9c
  24. Krisht AF : Transcavernous approach to diseases of the anterior upper third of the posterior fossa. Neurosurg Focus 19 : E2, 2005
  25. Kumon Y, Sakaki S, Kohno K, Ohta S, Ohue S, Oka Y : Asymptomatic, unruptured carotid-ophthalmic artery aneurysms : angiographical differentiation of each type, operative results, and indications. Surg Neurol 48 : 465-472, 1997 https://doi.org/10.1016/S0090-3019(97)00175-4
  26. Kyoshima K, Kobayashi S, Orz IO : Ophthalmic aneurysms in Kaye AH, Black P (eds) : Operative Neurosurgery. London : Harcourt Publishers, 2000, pp973-984
  27. Lanzino G, Wakhloo AK, Fessler RD, Hartney ML, Guterman LR, Hopkins LN : Efficacy and current limitations of intravascular stents for intracranial internal carotid, vertebral, and basilar artery aneurysms. J Neurosurg 91 : 538-546, 1999 https://doi.org/10.3171/jns.1999.91.4.0538
  28. Mikami T, Minamida Y, Koyanagi I, Baba T, Houkin K : Anatomical variations in pneumatization of the anterior clinoid process. J Neurosurg 106 : 170-174, 2007 https://doi.org/10.3171/jns.2007.106.1.170
  29. Mizoi K, Takahashi A, Yoshimoto T, Fujiwara S, Koshu K : Combined endovascular and neurosurgical approach for paraclinoid internal carotid artery aneurysms. Neurosurgery 33 : 986-992, 1993 https://doi.org/10.1227/00006123-199312000-00005
  30. Ogilvy CS : Paraclinoid carotid aneurysms in Ojemann RG, Ogilvy CS, Crowell RM, Heros RC (eds) : Surgical Management of Neurovascular Disease, ed 3. Baltimore : Williams & Wilkins, 1995, pp185-213
  31. Park HK, Horowitz M, Jungreis C, Kassam A, Koebbe C, Genevro J, et al. : Endovascular treatment of paraclinoid aneurysms: experience with 73 patients. Neurosurgery 53 : 14-23; discussion 24, 2003 https://doi.org/10.1227/01.NEU.0000068789.08955.1C
  32. Raco A, Frati A, Santoro A, Vangelista T, Salvati M, Delfini R, et al. : Long-term surgical results with aneurysms involving the ophthalmic segment of the carotid artery. J Neurosurg 108 : 1200-1210, 2008 https://doi.org/10.3171/JNS/2008/108/6/1200
  33. Ricci G, Ricci A, Gallucci M, Zotta D, Scogna A, Costagliola C, et al. : Combined endovascular and microsurgical approach in the treatment of giant paraclinoid and vertebrobasilar aneurysms. J Neurosurg Sci 49 : 1-6, 2005
  34. Rizzo JF : Visual loss after neurosurgical repair of paraclinoid aneurysms. Ophthalmology 102 : 905-910, 1995
  35. Shucart WA, Kwan ES, Heilman CB : Temporary balloon occlusion of a proximal vessel as an aid to clipping aneurysms of the basilar and paraclinoid internal carotid arteries : technical note. Neurosurgery 27 : 116-119, 1990 https://doi.org/10.1227/00006123-199007000-00017
  36. Tanaka Y, Hongo K, Tada T, Nagashima H, Horiuchi T, Goto T, et al. : Radiometric analysis of paraclinoid carotid artery aneurysms. J Neurosurg 96 : 649-653, 2002 https://doi.org/10.3171/jns.2002.96.4.0649
  37. Vinuela F, Duckwiler G, Mawad M : Guglielmi detachable coil embolization of acute intracranial aneurysm : perioperative anatomical and clinical outcome in 403 patients. J Neurosurg 86 : 475-482, 1997 https://doi.org/10.3171/jns.1997.86.3.0475
  38. Xu BN, Sun ZH, Jiang JL, Wu C, Zhou DB, Yu XG, et al. : Surgical management of large and giant intracavernous and paraclinoid aneurysms. Chin Med J (Engl) 121 : 1061-1064, 2008
  39. Yasargil MG, Gasser JC, Hodosh RM, Rankin TV : Carotid-ophthalmic aneurysms : direct microsurgical approach. Surg Neurol 8 : 155-165, 1977
  40. Zhao J, Wang S, Zhao Y, Sui D, Zhang Y, Tang J, et al. : Microneurosurgical management of carotid-ophthalmic aneurysms. J Clin Neurosci 13 : 330-333, 2006 https://doi.org/10.1016/j.jocn.2005.04.029
  41. Zipfel GJ, Day AL : Surgical treatment of paraclinoid internal carotid artery aneurysms in Batjer HH, Loftus CM (eds) : Textbook of Neurological Surgery. Philadelphia : Lippincott, Williams & Wilkins, 2003, pp 2372-2382

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