Aneurisma paraclinóideo: técnica cirúrgica e resultados em 51 pacientes

Abstract

RESUMO -Analisam-se 51 pacientes portadores de 55 aneurismas paraclinóideos (APC) submetidos a tratamento cirúrgico. Em decorrência de tratar-se de procedimento de alta complexidade, descrevemos em pormenor os seus aspectos técnicos. O processo clinóideo anterior foi removido por via extradural após secção da duplicação dural da tenda da fissura orbitária superior e/ou por via intradural. Conseguiu-se exclusão do APC nos 51 pacientes. Em dois casos a clipagem foi parcial e, em três, ocorreu oclusão da ACI. Em 42 (82%) pacientes ocorreu bom resultado; em 5 (10%), incapacidade moderada; em 1 (2%), incapacidade grave e três (6%) faleceram por infarto cerebral. Sete (13,7%) pacientes tiveram lesão adicional do nervo óptico, sendo parcial em 4 (7,7%) e total em 3 (6%). PALAVRAS-CHAVE: aneurismas paraclinóideos, aneurismas carótido-oftálmicos, artéria carótida interna, técnica cirúrgica. Paraclinoid aneurysms: surgical technique and results in 51 patientsABSTRACT -An analysis of the surgical results of 51 patients harboring 55 paraclinoid aneurysms is performed, along with a throughoutful description of it's complex microsurgical technique.The anterior clinoid process was removed by the extradural route after sectioning the dural duplication between the superior orbital fissure and the dura of the temporal lobe, and/or by the intradural approach. All 55 aneurysms was excluded. In two cases the clipping was partial and the internal carotid artery were ocluded in three cases. The surgical outcome was good in 42 (82%) patients, moderate incapacity occurred in five (10%) and severe incapacity in one patient (2%). Three patients (6%) died due to brain infarction. Seven patients (13,7%) had adicional lesion of the optic nerve, being partial in 4 (7,7%) and total in 3 (6%).KEY WORDS: paraclinoid aneurysms, carotid-ophthalmic aneurysms, internal carotid artery, operative technique.Os aneurismas paraclinóideos (APC), ou carótido-oftálmicos ou dos segmentos clinóideo e oftálmico da artéria carótida interna (ACI), são definidos como os aneurismas da ACI intratecal que se originam do segmento que é delimitado proximalmente pelo anel dural proximal e distalmente por um círculo imaginário em torno da ACI, na emergência da artéria comunicante posterior 1 .A incidência dos APC varia de 1,5 a 8% entre todos os aneurismas intracranianos. Eles formam um subgrupo especial em decorrência das dificuldades na abordagem determinadas pelas íntimas relações desses aneurismas com o nervo óptico, nervo oculomotor, seio cavernoso e processo clinóideo anterior. Como nos aneurismas em geral, os APC manifestam-se geralmente por ruptura e hemorragia subaracnóidea. . Ele propôs a remoção extradural do processo clinóideo anterior, do teto da órbita e das paredes superior e lateral do canal óptico para propiciar melhor exposição desses aneurismas.O objetivo deste estudo é revisar a técnica microcirúrgica usada na exposição completa dos segmentos clinóideo e oftálmico (segmento paraclinóideo) da ACI, no sentido de expor e clipar os APC, e relatar o resul...

Cavernous Carotid Artery Giant Aneurysm: Case Report and Literature Review

“…Cavernous carotid aneurysms represent 2% of all intracranial aneurysms. 3 Most aneurysms of this type are considered benign lesions, considering that 18% of the cases are asymptomatic and have a natural history with a low rate of life-threatening complications, promoting, less frequently, symptoms by means of rupture, leading to a subarachnoid hemorrhage (SAH), severe epistaxis or even embolic events, generating a possible ischemic stroke. 5,6 However, in the case of giant aneurysmal formations, intracavernous aneurysms invariably promoted symptoms as a consequence of neurovascular compression, 6 which contrasts with the present case report, in which the giant aneurysm was discovered at random in an asymptomatic patient.…”

“…2 Those which are present in the cavernous carotid artery represent 2% of the cases. 3 Prevalently, the natural history of giant intracranial aneurysms is severe. More than 50% of the patients suffer a rupture of these aneurysms and the mortality is higher than 60% in 2 years.…”

Complex paraclinoidal and giant cavernous aneurysms: importance of preoperative evaluation with temporary balloon occlusion test and SPECT

“…Direct surgical repair of intracavernous aneurysms is associated with high morbidity of the intracavernous nerves and is rarely used nowadays. Endovascular therapy with preservation of the patency of the parent vessel in these frequently giant aneurysms with broad necks is still not satisfactory with current The majority of large and giant supraclinoidal aneurysms can be managed by direct surgical clip ligation using a variety of technical adjuncts including temporary occlusion with cerebral protection, and aneurysm deflation with retrograde suction [7][8][9][10][11][12] . However, some giant and dimorphic paraclinoidal aneurysms are simply not amenable to direct clip ligation or endovascular obliteration because of very large neck, proximal extension into the cavernous sinus, dense calcification of the neck, intraluminal organized thrombus, or other physical factors that preclude obliteration of the sac with preservation of the parent vessel.…”