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Third nerve decompression by anterior petroclinoid ligament opening after clipping of posterior communicating artery aneurysm—How I do it

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Abstract

Background

Posterior communicating artery aneurysms sometimes present with partial or complete oculomotor nerve palsy, due to direct oculomotor nerve compression, irritation by subarachnoid blood, or both. Superiority of surgical clipping over endovascular coiling in terms of postoperative outcome is still controversial.

Method

Direct oculomotor nerve decompression by opening of the anterior petroclinoid ligament during aneurysm clipping is performed as a simple and feasible surgical maneuver which allows to improve the decompression effect obtained by aneurysm exclusion.

Conclusion

Anterior petroclinoid ligament opening permits to achieve a better oculomotor nerve decompression. Its efficiency on the recovery of the deficit needs to be proved by larger series.

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Abbreviations

ONP:

Oculomotor nerve palsy

PCoA:

Posterior communicating artery

References

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Author information

Correspondence to Lorenzo Bertulli.

Additional information

Key points

• A frequent presentation of PCoA aneurysms is ONP, which can be partial or complete

• ONP is probably caused by direct compression of the aneurysm, its pulsations and/or the irritation of subarachnoid blood

• Surgical clipping may be superior in terms of ONP recovery because indirectly decompresses the nerve after aneurysm exclusion, but there is still debate on it

• A large amount of studies conclude that the two treatment options are almost the same

• Anterior petroclinoid ligament is a dural fold which sometimes creates an additional compression on the oculomotor nerve

• During surgery, after the placement of the clip, a small opening can be made in this tentorial extension to directly decompress the nerve

• This maneuver has previously described only for surgical purposes, in order to better visualize aneurysm neck

• The technique for direct decompression is quite feasible and could be performed during standard surgery without any specific or complex instrumentation

• The direct nerve decompression, when it can be performed, creates an additional beneficial effect on the nerve

• This results in shorter recovery time and better functional outcome

This article is part of the Topical Collection on Neurosurgical Anatomy

Electronic supplementary material

The video shows the key phases of the surgical procedure. In the first phase, a sharp arachnoid dissection is performed to carefully expose the aneurysm neck. After that, the clip is placed and the aneurysm is excluded from circulation, with verification by ultrasound probe. In the end, a 4–5 mm long opening in the anterior petroclinoid ligament is performed to decompress the third cranial nerve to improve the postoperative visual outcome. ICA, internal carotid artery; ON, optic nerve; Third CN, third cranial nerve. Note: The patients gave us the consent to publish the video in an anonymous way.(MP4 243198 kb)

Video 1

The video shows the key phases of the surgical procedure. In the first phase, a sharp arachnoid dissection is performed to carefully expose the aneurysm neck. After that, the clip is placed and the aneurysm is excluded from circulation, with verification by ultrasound probe. In the end, a 4–5 mm long opening in the anterior petroclinoid ligament is performed to decompress the third cranial nerve to improve the postoperative visual outcome. ICA, internal carotid artery; ON, optic nerve; Third CN, third cranial nerve. Note: The patients gave us the consent to publish the video in an anonymous way.(MP4 243198 kb)

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Bertulli, L., Reinert, M. & Robert, T. Third nerve decompression by anterior petroclinoid ligament opening after clipping of posterior communicating artery aneurysm—How I do it. Acta Neurochir 160, 2187–2189 (2018) doi:10.1007/s00701-018-3666-x

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Keywords

  • Aneurysm
  • Clipping
  • Oculomotor nerve palsy
  • Posterior communicating artery