J Korean Neurosurg Soc.  2013 Dec;54(6):477-483. 10.3340/jkns.2013.54.6.477.

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

• Lee SK
• Kim JM

• KMID: 2190942
• DOI: http://doi.org/10.3340/jkns.2013.54.6.477

Abstract

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.

Keyword

Clinoidectomy; Orbito-zygomatic craniotomy; Paraclinoid aneurysm; Large and giant; Microsurgical clipping

MeSH Terms

Aneurysm*
Angiography
Angiography, Digital Subtraction
Arteries
Carotid Artery, Internal*
Craniotomy
Neck
Optic Nerve
Surgical Instruments

Figure

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  Fig. 1 Preoperative left digital subtraction angiography (DSA) (A, B and C) demonstrating a giant (60×55 mm sized sac) left internal carotid artery (ICA) posterior wall aneurysm. Contrast media mainly accumulated due to rapid shunting flow into the giant non-thrombosed aneurysm sac, resulting in poor visualization of the proximal and distal ICA flow. A : Anteroposterior view. B : lateral view. C : anterooblique view of three-dimensional (3-D) DSA. Preoperative 3-D computed tomographic (CT) angiography (D) showing a giant sac adheres to all of the surrounding anterior and posterior cerebral arteries on both sides. Postoperative left 3-D DSA (E, F and G) demonstrating complete obliteration of a giant ICA posterior wall aneurysm sac and the entire reconstructed length of ICA with preservation of ophthalmic artery using a clipping technique of eight different shapes of fenestrated clips. E : Anteroposterior view. F : lateral view. G : lateral view of 3-D DSA. Postoperative 3-D CT angiography (H) showing the preservation of the left anterior and middle cerebral vascular trees.

• 

  Fig. 2 Preoperative left carotid digital subtraction angiography (DSA) (A-D) demonstrating a large (12×10 mm sized sac) left carotid cave aneurysm. A : Anteroposterior view. B : lateral view. C : anteroposterior view of three-dimensional (3-D) DSA. D : lateral view of 3-D DSA. The ophthalmic and posterior communicating arteries are closely related with the aneurysm. Postoperative left carotid DSA (E-H) demonstrating a complete occlusion of a large carotid cave aneurysm sac and reconstructed proximal internal carotid artery with sparing of the left ophthalmic and posterior communicating arteries using six various types of aneurysm clips. E : Anteroposterior view. F : lateral view. G : medial view of 3-D DSA. H : mediolateral view of 3-D DSA.

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