• Journal of Korean Neurosurgical Society
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• v.30 no.sup2
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• pp.203-210
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• 2001

Objective : Paraclinoidal aneurysms termed that aneurysms arising from proximal internal carotid artery(ICA) between the site of emergence of the carotid artery from roof of the cavernous sinus and origin of the posterior communicating artery(PCoA). These aneurysms pose conceptual and technical surgical problems with regard to acquisition of proximal control and safe intracranial exposure. The efficiency of surgical technique according to the location of paraclinoidal aneurysm was studied for minimal exposure. Materials and Methods : Over the past four years, the authors treated surgically 171 cases of cerebral aneurysm, among them ten patients were paraclinoidal aneurysms with two patients unruptured aneurysms. Mean age was 47 years old, and all patients were female. Three patients were proximal posterior carotid artery wall aneurysms(one large, one giant), four patients carotid-ophthalmic artery aneurysms and three patients superior hypophyseal artery aneurysms. Results : There could be done clip in all cases, there were no deaths and no complication. And no patient developed sustained neurological deficits including visual function except hydrocephalus in one case. Four patients complained of visual disturbance but two patients had recovery after postoperation and two patient were not longer to bad. Conclusion : Our recent experience suggests that preoperative scrutiny of diagnostic angiography allows classification of all paraclinoidal aneurysms regardless of size and surgical technique which this classification has focused on operative approaches unique to each aneurysm projection was helpful to improve the operative outcome with good visual function and to shorten the operative time.

• Journal of Korean Neurosurgical Society
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• v.47 no.6
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• pp.437-441
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• 2010

Objective : The precise intra- vs. extradural localization of aneurysms involving the paraclinoid internal carotid artery is critical for the evaluation of patients being considered for aneurysm surgery. The purpose of this study was to investigate the clinical usefulness of T2-weighted threedimensional (3-D) fast spin-echo (FSE) magnetic resonance (MR) imaging in the evaluation of unruptured paraclinoid aneurysms. Methods : Twenty-eight patients with unruptured cerebral aneurysms in their paraclinoid regions were prospectively evaluated using a T2- weighted 3-D FSE MR imaging technique with oblique coronal sections. The MR images were assessed for the location of the cerebral aneurysm in relation to the dural ring and other surrounding anatomic compartments, and were also compared with the surgical or angiographic findings. Results : All 28 aneurysms were identified by T2-weighted 3D FSE MR imaging, which showed the precise anatomic relationships in regards to the subarachnoid space and the surrounding anatomic structures. Consequently, 13 aneurysms were determined to be intradural and the other 15 were deemed extradural as they were confined to the cavernous sinus. Of the 13 aneurysms with intradural locations, three superior hypophyseal artery aneurysms were found to be situated intradurally upon operation. Conclusion : High-resolution T2-weighted 3-D FSE MR imaging is capable of confirming whether a cerebral aneurysm at the paraclinoid region is intradural or extradural, because of the MR imaging's high spatial resolution. The images may help in identifying patients with intradural aneurysms who require treatment, and they also can provide valuable information in the treatment plan for paraclinoid aneurysms.

• Journal of Korean Neurosurgical Society
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• v.54 no.6
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• pp.477-483
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• 2013

Objective : Although surgical techniques for clipping paraclinoid aneurysms have evolved significantly in recent times, direct microsurgical clipping of large and giant paraclinoid aneurysms remains a formidable surgical challenge. We review here our surgical experiences in direct surgical clipping of large and giant paraclinoid aneurysms, especially in dealing with anterior clinoidectomy, distal dural ring resection, optic canal unroofing, clipping techniques, and surgical complications. Methods : Between September 2001 and February 2012, we directly obliterated ten large and giant paraclinoid aneurysms. In all cases, tailored orbito-zygomatic craniotomies with extradural and/or intradural clinoidectomy were performed. The efficacy of surgical clipping was evaluated with postoperative digital subtraction angiography and computed tomographic angiography. Results : Of the ten cases reported, five each were of ruptured and unruptured aneurysms. Five aneurysms occurred in the carotid cave, two in the superior hypophyseal artery, two in the intracavernous, and one in the posterior wall. The mean diameter of the aneurysms sac was 18.8 mm in the greatest dimension. All large and giant paraclinoid aneurysms were obliterated with direct neck clipping without bypass. With the exception of the one intracavenous aneurysm, all large and giant paraclinoid aneurysms were occluded completely. Conclusion : The key features of successful surgical clipping of large and giant paraclinoid aneurysms include enhancing exposure of proximal neck of aneurysms, establishing proximal control, and completely obliterating aneurysms with minimal manipulation of the optic nerve. Our results suggest that internal carotid artery reconstruction using multiple fenestrated clips without bypass may potentially achieve complete occlusion of large paraclinoid aneurysms.

• Journal of Korean Neurosurgical Society
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• v.63 no.2
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• pp.137-152
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• 2020

In spite of the developing endovascular era, large (15-25 mm) and giant (>25 mm) wide-neck cerebral aneurysms remained technically challenging. Intracranial flow-diverting stents (FDS) were developed to address these challenges by targeting aneurysm hemodynamics to promote aneurysm occlusion. In 2011, the first FDS approved for use in the United States market. Shortly thereafter, the Pipeline of Uncoilable or Failed Aneurysms (PUFS) study was published demonstrating high efficacy and a similar complication profile to other intracranial stents. The initial FDA instructions for use (IFU) limited its use to patients 22 years old or older with wide-necked large or giant aneurysms of the internal carotid artery (ICA) from the petrous segment to superior hypophyseal artery/ophthalmic segment. Expanded IFU was tested in the Prospective Study on Embolization of Intracranial Aneurysms with PipelineTM Embolization Device (PREMIER) trial. With further post-approval clinical data, the United States FDA expanded the IFU to include patients with small or medium, wide-necked saccular or fusiform aneurysms from the petrous ICA to the ICA terminus. However, IFU is more restrictive in South Korea than in United States. Several systematic reviews and meta-analyses have sought to evaluate the overall efficacy of FDS for the treatment of cerebral aneurysms and consistently identify FDS as an effective technique for the treatment of aneurysms broadly with complication rates similar to other traditional techniques. A growing body of literature has demonstrated high efficacy of FDS for small aneurysms; distal artery aneurysms; non-saccular aneurysms posterior circulation aneurysms and complication rates similar to traditional techniques. In the short interval since the Pipeline Embolization Device was first introduced, FDS has been firmly entrenched as a powerful tool in the endovascular armamentarium. As new FDS are developed, established FDS are refined, and delivery systems are improved the uses for FDS will only expand further. Researchers continue to work to optimize the mechanical characteristics of the FDS themselves, aiming to optimize deploy ability and efficacy. With expanded use for small to medium aneurysms and posterior circulation aneurysms, FDS technology is firmly entrenched as a powerful tool to treat challenging aneurysms, both primarily and as an adjunct to coil embolization. With the aforementioned advances, the ease of FDS deployment will improve and complication rates will be further minimized. This will only further establish FDS deployment as a key strategy in the treatment of cerebral aneurysms.