Abstract
Background
The management of complex paraclinoid aneurysms is still challenging. In this article we describe our approach to paraclinoid aneurysms, which has evolved over several years, using an exclusively intradural approach.
Method
All procedures are done under continuous electrophysiological monitoring. A standard pterional approach is used to access the paraclinoid region exclusively intraduraly. After optic nerve unroofing and tailored clinoidectomy, the aneurysm neck is visualized and clipped using the tandem clipping technique and suction decompression if necessary. Aneurysm occlusion is verified using intraoperative ICG angiography and postoperative 3D DSA.
Conclusion
The exclusively intradural approach to complex paraclinoid aneurysms with tailored clinoidectomy offers an excellent surgical corridor for the treatment of these challenging lesions.
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Comment
The authors of this excellent and well-illustrated paper developed a technique of intradural tailored resection of the anterior clinoid process (ACP). Basically the main advantage of the radical extradural resection is to offer an optimal early decompression of the optic canal and optic nerve. The extradural resection of this small canine-like bony volume can be achieved safely and in a short time using reliable landmarks. Despite the fact that one can be reluctant to drill against the hidden wall of an aneurysm, there is little risk to damage it if care is taken to check the ACP anatomy and rule out potential bony erosion on the preoperative bony CT. However, there is little matter showing that ACP resection should be carried out in an intra- or extradural way; the issue is to be trained and confident with one of these techniques and achieve an entire visualization of the aneurysm neck and origin of the ophthalmic artery while decompressing the optic nerve.
Pierre-Hugues Roche
Marseille, France
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Seifert, V., Güresir, E. & Vatter, H. Exclusively intradural exposure and clip reconstruction in complex paraclinoid aneurysms. Acta Neurochir 153, 2103–2109 (2011). https://doi.org/10.1007/s00701-011-1171-6
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DOI: https://doi.org/10.1007/s00701-011-1171-6