Surgical Treatment of Posterior Communicating Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

Abstract

Background In spite of the advent of neurointerventional treatment, different clinical and anatomical features are still strong indications for clipping of posterior communicating artery (PComA) aneurysms. But the experience of young neurosurgeons is increasingly limited, and therefore providing technical operative guidelines is a fundamental prerequisite to achieve the best aneurysm exclusion and avoid perioperative complications. Study Objective We describe a technical algorithm we use to teach young neurosurgeons how to approach carotid aneurysms that may help them develop a procedural memory and thus perform an efficient and safe surgery. Material and Methods We reviewed our last 10 years of institutional experience of > 150 cases of clipping ruptured and unruptured PComA aneurysms, analyzing our technical refinements and the difficulties in teaching residents and young neurosurgeons how to establish fundamental key points and design a didactic algorithm that includes operative instructions and safety rules. Results We recognized seven pragmatic technical key points regarding craniotomy, cisternostomy, proximal and distal control, aneurysm neck dissection, preservation of neurovascular structures, and clipping to use in a didactic algorithm for teaching residents and as operative instructions for inexperienced neurosurgeons. Conclusion In the setting of clipping PComA aneurysms, respect for surgical rules is of paramount importance to perform an efficacious and safe procedure and ensure the best aneurysm exclusion and preservation of neurovascular structures.

Strategies for Optic Pathways Decompression for Extra-Axial Tumors or Intracranial Aneurysms: A Technical Note

“…Even though proximal control can be secured at the extracranial ICA, a certain optic nerve manipulation is necessary to expose the aneurysm neck. [16][17][18] Thus, FL opening, unroofing of the optic canal, and drilling of the anterior clinoid process and optic strut can be necessary before the aneurysm clipping. The larger the aneurysm size, the greater the usefulness of these maneuvers.…”

“…Posterior communicating artery aneurysms originate from the ICA segment between the origin of the posterior communicating artery and the ICA bifurcation and point toward the lateral carotid cistern. 16 Generally, they do not result in direct compression of the optic pathways unless they are giant size. Nevertheless, in some circumstances, optic nerve manipulation may be necessary to guarantee proximal control for any temporary clipping, especially if the proximal ICA is <3 mm.…”

“…Nevertheless, in some circumstances, optic nerve manipulation may be necessary to guarantee proximal control for any temporary clipping, especially if the proximal ICA is <3 mm. 16,17 Carotid cave aneurysms originate from the medial wall of the paraclinoid ICA, between the distal dural ring and the origin of the ophthalmic artery, and represent 7 to 17% of all paraclinoid aneurysms. 19 Because of their medial projection, clippings should be done in such a way that the optic nerve is mobilized medially and the ICA laterally.…”

Surgical Treatment of Anterior Communicating Artery Aneurysms: Hints and Precautions for Young Cerebrovascular Surgeons

“…lamina terminalis does not guarantee the prevention of a posthemorrhagic hydrocephalus. 9 Some AComA aneurysms are more similar to a dysplasia of the communicating artery rather than saccular malformations with a true neck. In these cases, especially when one of the two A1s appears hypoplastic, the AComA must always be preserved to guarantee the flow in the A2s.…”

“…Thus having simple operative guidelines and a safety algorithm is key because of the increasingly limited experience of the new generation of vascular neurosurgeons. [6][7][8][9]…”