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Surgical nuances of giant paraclinoid aneurysms

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Abstract

Paraclinoid aneurysms constitute formidable surgical challenge. The complex surgical anatomy and several factors such as size and projection of the lesion, choice of the surgical approach, relationships between the aneurysm and perforator vessels, site of proximal control, and potential improvement or worsening of visual symptoms account for these difficulties. In such complex cases, surgical nuances frequently determine the final outcome. In this paper, the authors present a comprehensive review of the tricky regional anatomy and describe the operative nuances one of the senior authors (E. dO.) has used to operate on these complex lesions.

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Author information

Authors and Affiliations

  1. Division of Neurological Surgery, School of Medicine, University of São Paulo, Rua Oscar Freire, 1399, AP 171, CEP 05409-010, São Paulo, SP, Brazil

    Eberval Gadelha Figueiredo & Wagner Malagó Tavares

  2. Department of Neurological Surgery, University of Florida, Gainesville, FL, USA

    Albert L. Rhoton Jr.

  3. Department of Neurological Surgery, State University of Campinas and Instituto De Ciencias Neurologicas, Campinas, Sao Paulo, Brazil

    Evandro De Oliveira

Authors
  1. Eberval Gadelha Figueiredo
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  2. Wagner Malagó Tavares
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  3. Albert L. Rhoton Jr.
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  4. Evandro De Oliveira
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Corresponding author

Correspondence to Eberval Gadelha Figueiredo.

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Comments

Mikael Svensson, Stockholm, Sweden

The authors of this article present a comprehensive review of the paraclinoidal anatomy and describe operative nuances used to manage giant aneurysm in this region. Surgical approaches of paraclinoid aneurysms have significantly improved based on anatomic studies of the paraclinoid and cavernous sinus regions, and to cite the authors: “demystifying what was previously reckoned as a no man's hand land”. However, surgery of paraclinoid aneurysms still represents a major surgical challenge mainly because of the tricky regional anatomy. The classification of paraophthalmic aneurysm is somewhat confusing which is discussed by the authors, and they present a simplified and very useful scheme that is helpful not only for the understanding of the anatomy but also for choice of surgical approach and strategy for clipping. The authors describe in detail the surgical steps on how to approach giant paraophthalmic aneurysm in order to minimize risk for visual deficits and damage of perforators by a gradual exposure of the extradural and intradural compartments of the carotid artery and meticulous microdissection of the sylvian fissure. Many factors may influence the surgical planning of aneurysms in the paraclinoid region such as anatomical relationships, features of the lesion, preoperative visual function, and preoperative management of the optic nerves as well as possible target sites for proximal control. In this paper that should be of interest for all vascular neurosurgeons, the authors present an excellent review of the complicated regional anatomy and describe the operative nuances that frequently determine the final outcome. The paper sets not only focus on the role of microsurgery but also the importance of preoperative evaluation with aspects concerning risk–benefit-analyses. The latter is for, natural reasons, difficult since the literature is limited. Prediction of outcome prior to intervention is difficult for the same reason. Learning from experienced neurosurgeons in this format is therefore of great importance for future vascular neurosurgeons. In summary, the authors have put a lot of effort in summarizing their own and others experience in this complex field, and hopefully, we will read more from this group in the future.

Giuseppe Esposito, Rome, Italy

Luca Regli, Utrecht, The Netherlands

Large and giant paraclinoid aneurysms (PCAs) remain a major challenge for vascular neurosurgeons due to their location in proximity of neural, vascular, and bony structure. A wide knowledge of the local anatomy along with the specific technical surgical skills is mandatory in the management of these lesions. Figueiredo, Rhoton, and Oliveira present in this issue a paper on surgical nuances of giant paraclinoid aneurysms.

The difficulty in classifying these aneurysms reflects the complex anatomy of paraclinoid region: in fact, many classifications have been proposed. We appreciate the authors' simplification identifying only two basic variants of giant PCAs: in the first type, the aneurysm is directed upward, in the second one, downward. They consider all other projections a subset of these two variants and show that clinical symptoms, surgical planning, and clip application depend upon the type of the projection.

An accurate preoperative neuroradiological examination is mandatory. CT and MR imaging and angiography with digital subtraction angiographic imaging with 3D reconstructions, offer detailed information about the relationship of the aneurysm to venous and nerve structures. (1)

The “gold standard” for the treatment of giant PCAs remains surgical clipping. Although there are a wide variety of endovascular therapeutic options, none of the current techniques is completely successful and free of complications in the management of these complex lesions. In fact, surgery can reduce rates of recurrence and embolic complications [2] as also confirmed by our experience. The published endovascular series reported lower occlusion rates either in ruptured or unruptured lesions. Some of these difficult aneurysms with high potential risks for both surgery and embolization are not prone for direct reconstruction and should be treated with parent artery occlusion combined with bypass-protection when indicated (3, 6).

Surgical resection of giant aneurysms with or without parent artery sacrifice might be effective also in refractory cases after coil embolization. After coiling, giant aneurysms might continue to grow due to a hypertrophic vasa vasorum and subadventitial hemorrhages: this should be kept in mind as a possible etiology in the progression of giant PCAs (2).

Surgical treatment has also benefited from advances in anesthesiology and neuroprotection techniques, in intraoperative neurophysiological monitoring, and angiography. After surgical clipping, we always perform intraoperative indocyanine-green fluorescence videoangiography and intraoperative flow measurements, which provide real-time information on the completeness of aneurysm exclusion and vessels patency. The image quality and spatial resolution of intraoperative fluorescence angiography allows checking permeability of perforating vessels.

Giant PCAs aneurysms can have large and calcified neck, involve parent and collateral vessels, and be partly thrombosed. In these cases, the possibility of the aneurysm refilling after clip application must be considered. Closure of the neck by only one clip might ultimately be incomplete because of possible slippage or migration of clip blades. In most cases, one or two additional clips are added to reinforce the aneurysm neck occlusion.

Protection of the optic nerve must remain a paramount concern when treating paraclinoid aneurysms. Postoperative adverse events can be due to heat injury to the optic nerve during drilling of the optic canal, manipulation of the optic nerve during dissection from the aneurysm, ischemia of the optic pathway, and direct compression of the optic nerve by the applied clip. Despite recent technical advancements enabling remarkable risk reduction of this complication, postoperative deterioration of visual function remains a significant problem (4). Either ultrasonic bone curettage or a no-drill technique has been proposed in order to eliminate the risks of direct power-drilling mechanical/thermal injury (5). However, we still advocate, as described in this paper, an intradural microsurgical approach with high-speed power-drilling technique of anterior clinoidectomy as a safer and more controlled method. Thorough anatomic knowledge allows following the important principles presented by the authors. We fully agree on the importance of each surgical step described by the authors. There is only one surgical step that we systematically add: opening of the falciform ligament. In our hands, this manoeuvre has been extremely helpful in protecting optic nerve function. In 28 consecutive anterior clinoidectomies (12 for meningiomas and 16 paraclinoid aneurysms) we have not encountered visual worsening.

This is an excellent review of paraclinoid surgical anatomy and operative skills in the surgical management of patients with giant PCAs. The authors have provided a more simple classification of paraclinoid aneurysms and have presented a rational clip application approach. We think vascular neurosurgeons will benefit from this addition to the literature based on a lifelong experience of the senior authors.

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Vinko V. Dolenc, Ljubljana, Slovenia

Complete understanding of normal anatomy of the sellar, suprasellar, and parasellar regions is an unconditioned must for understanding the pathological anatomy of the carotid ophthalmic aneurysms (COAs). Size, “geography,” and projection of the aneurysm are important; however, much less than the knowledge of the normal and pathological anatomy. There is no “tricky” anatomy. The anatomy is the anatomy, and one either understands it or not. How a surgeon deals with the COAs, how the proximal and distal controls are applied, what the collateral damage might be…does not depend on the pathology only but much more on the surgeon's dealing with this surgical challenge. The authors are of the opinion that the name “paraclinoid aneurysms (PCAs)” is more appropriate than the term “carotid–ophthalmic (segment) aneurysms (COA)”. This does remain an open question since not all the medially oriented “bulgings” from the ICA may fit into their—the authors'—terminology. Among other anatomical descriptions, one should be critical towards the statement that the ACP always projects into the cavernous sinus (CS) posterior to the anterior loop (AL) of the ICA. This might be true, but it is also not true in many cases as it was initially described in connection with the description of the AL of the ICA. The so-called window of the “anteromedial triangle” after complete removal of the anterior clinoid process (ACP) has been described accordingly (1, 7, 8) as an epidural triangle. It's also been described that the membrane (periosteum) around the ACP does separate the venous contents of the CS from the space of the ACP. And this is the point: whether the CS is to be opened at the extradural removal of the ACP or not. The distal (dural) ring (DR) represents the frontier between the extradural and intradural ICA (1–7). The ophthalmic artery does represent another “little dispute” regarding its origin and coursing. In our experience, the percentage of extradural origin of the ophthalmic artery from the ICA is more an exception than a solid percentage (1, 7). The classification of the aneurysms harboring in the initial intradural segment of the ICA has been discussed again and again (4, 7). It is well known that the COAs may present themselves as any other aneurysm with SAH or—above a certain size (large/giant)—as space occupying lesions. It goes without saying that the presentation of large/giant COAs is much higher as space-occupying lesions in comparison with cases of SAH. Dissecting the visual apparatus in particular from the ipsilateral optic nerve is crucial and has been described in detail (7). The exact and detailed description of the approach to that very corner has been published (1, 3, 4, 6, 7). However, we did not find it necessary to resect the medial wall of the optic canal because it is not necessary, and it does not bring any useful additional space for handling with COA. On the other hand, injury to the wall of the sphenoid sinus elevates significantly the risk for the cerebrospinal fluid leakage. The removal of the optic strut is necessary in this kind of surgeries; however, it should be performed very cautiously as was also already described and published in detail (1, 4, 7). It is difficult to agree with the authors regarding the true ophthalmic aneurysms. “Those with superior or superomedial projections”. Again it is the question of agreement.

Having experience with more than 3,000 extradural approaches to the optic canal and performing resections of the ACP extradurally for aneurysms and tumors, I find it difficult to accept the intradural rather than the extradural approach for the resection of the ACP. According to my experience, the intradural resection of the ACP carries much higher risk for the lesioning of the aneurysm, the optic nerve, and/or ICA. The intradural resection of the ACP is an extremely dangerous surgical act for the “beginners” in this kind of surgery and according to my opinion, should not be advised—in such literature. All the COAs could and should be excluded with clipping or resection of the aneurysm and reconstruction of the ICA without any retraction of the brain. Dealing with the optic nerve should be “indirect” in the optic canal—lifted by the dura and extremely gently behind the falciform ligament. The ICA should be identified at the tip of the AL of the ICA extradurally and following the splitting of the sylvian fissure at the bifurcation of the ICA into the ACA and MCA. It is self-evident that the PCom and the anterior choroidal artery should be dissected properly too. Only then is circumferential section of the DR allowed and possible. The incision of the dura along the sylvian fissure has also been precisely described, and it has been explained why (4, 7, 8). In order to prevent the venous bleeding from the CS, it is not practical to denude the ICA but only to dissect it from the wall of the sphenoid sinus in order to prepare it for the temporary clipping when necessary. For the proper positioning of the clip(s), it is mandatory to cut the DR circumferentially around the ICA, which enables necessary mobilization of the ICA proximal to the aneurysm. Again, this was described and published (1, 4, 7, 8), and it was shown that the size and projection of the aneurysm as well as the neck involvement in the ICA wall dictate the type of exclusion of the COA either with clipping or reconstruction of the ICA and preservation of the artery patency.

The author also mentioned that those COAs projecting downward and backward require opening and emptying and the ICA reconstructed. This was published already long ago (2, 4, 6). Furthermore, it was also published that, in such cases, the dome of the L/G COA should be left in place in order not to damage the perforators for the hypothalamus and upper brain stem (7). According to our experience, the proximal control might be at the cervical, petrous, and/or at the AL of the ICA segment. I do not see any contraindication for the exposure of the ICA in the petrous canal. However, in our practice, we use proximal control at the level of the AL of the ICA. And for the beginners, I do agree that the safest place for temporary clipping of the ICA is at the neck. The lesioning of the visual apparatus is extremely rare in a proper approach to COAs. The constant irrigation of the tip of the diamond drill while resecting the ACP, the walls of the optic canal, and/or the optic strut is a must. However, it is equally important to perform only a few revolutions with the drill and then to check the situation, in such a way that no morphological damage to the optic nerve, as well as no damage because of the heat will occur. But again, the extradural approach and resection of the ACP and optic strut and other bony compartment is essential.

In this very important report, I personally agree with most of the statements. My remarks are directed to the evolution of this approach—as it is presented—and that is that many facts were published already in the last decades of the previous century. Having a vast experience with the epidural resection of the ACP, removal of the lateral and superior walls of the optic canal, as well as resection of the optic strut, I cannot agree with the statement of the authors that the intradural approach and resection of the ACP is superior to the extradural. I have to warn all the beginners that the extradural approach is, according to my experience, superior to the intradural.

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Figueiredo, E.G., Tavares, W.M., Rhoton, A.L. et al. Surgical nuances of giant paraclinoid aneurysms. Neurosurg Rev 33, 27–36 (2010). https://doi.org/10.1007/s10143-009-0224-2

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