Internal Carotid Artery Reconstruction Using Multiple Fenestrated Clips for Complete Occlusion of Large Paraclinoid Aneurysms

Abstract

ObjectiveAlthough 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.MethodsBetween 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.ResultsOf 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.ConclusionThe 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.

Clipping Ophthalmic Segment Artery Aneurysms Using a Modified Subdural Dolenc Approach: Classification and Experience Sharing

“…22 Direct surgical clipping has great durability and can not only eliminate the mass effect of the body but also reduce the cost of surgery to some extent. 10,23,24 In our 4 cases of large OSA with visual impairment, the aneurysm bodies were partly adherent to the ON. We resected the excess aneurysmal wall after clipping the aneurysm.…”

“…However, the lateral edge of the range of the modified subdural Dolenc approach extends from the medial half of the incisura supraorbitalis to the tip of the ACP, and this approach also requires the reconstruction of the ACP (Figure 5). We used the modified subdural Dolenc approach to remove the ACP in most of our patients, which reduced the extent of abrasion compared with the traditional epidural [10][11][12][13] and subdural approaches, [14][15][16] but did not affect the mobilization of the ON or the exposure of the distal dural ring. The modified subdural Dolenc approach in our research has a lower incidence of complications, such as cerebrospinal fluid leakage and injury of the ON and ICA.…”