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Ruptured anterior paraclinoid aneurysms

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Abstract

The purpose of this study was to evaluate cases of subarachnoid hemorrhage (SAH) from ruptured anterior (dorsal) paraclinoid aneurysms. Anterior paraclinoid aneurysms are defined as aneurysms arising from the anterolateral wall of the proximal internal carotid artery without any relationship to an arterial branch. Between 1991 and 2008, a total of 159 patients with 169 paraclinoid aneurysms were treated at the Shinshu University Hospital and its affiliated hospitals. A retrospective analysis was carried out using charts, operation records, operation videos, and neuroimagings. Twenty six patients had anterior paraclinoid aneurysm. Six patients presented with SAH. Three aneurysms were saccular and the others were blister-like aneurysms based on operative findings. Neck laceration or premature rupture frequently happened during the clipping surgery even though the aneurysm was saccular type. The treatment of a ruptured anterior paraclinoid aneurysm is quite difficult. Trapping and bypass would be recommended for such fragile aneurysms.

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Authors and Affiliations

  1. Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan

    Tetsuyoshi Horiuchi, Yoshikazu Kusano, Takehiro Yako, Takahiro Murata, Yukinari Kakizawa & Kazuhiro Hongo

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  1. Tetsuyoshi Horiuchi
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  2. Yoshikazu Kusano
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  3. Takehiro Yako
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  4. Takahiro Murata
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  5. Yukinari Kakizawa
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  6. Kazuhiro Hongo
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Correspondence to Tetsuyoshi Horiuchi.

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Comments

Michael T. Lawton, San Francisco, United States

This study presents an experience with 26 anterior paraclinoid or dorsal internal carotid artery (ICA) aneurysms, defined as arising from the anterolateral ICA wall unrelated to a branch artery. Six of these patients presented with subarachnoid hemorrhage, of which three were blister aneurysms. Surgical treatment of these ruptured aneurysms resulted in premature rupture or neck laceration in four cases, highlighting the fragile nature of these aneurysms and the small amount of tissue at the aneurysm neck to work with. Based on these experiences, the authors treated their last ruptured aneurysm with STA-MCA bypass followed by an ECA-MCA bypass with radial artery graft and trapping, with good results. The authors conclude by recommending this treatment strategy. I share the authors' respect for these aneurysms and agree that preparations for bypass must be made. However, I consider bypass-trapping as the alternative plan. I like to inspect the aneurysm and maybe attempt direct clipping first before proceeding to bypass-trapping. I prefer the ECA-MCA bypass using a radial artery graft over a low-flow STA-MCA bypass when sacrificing ICA, but have not found that both bypasses are necessary.

I commend the authors on their work. Anterior paraclinoid aneurysms are more treacherous than they appear angiographically, and the neurosurgeon must be ready to deal with slipping clips, intraoperative ruptures, and arterial lacerations using sophisticated techniques that include anterior clinoidectomy, complex clipping, and bypass. Surgery remains the treatment of choice for many of these aneurysms because their small size, broad necks, and sessile morphology make them difficult to coil successfully.

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Horiuchi, T., Kusano, Y., Yako, T. et al. Ruptured anterior paraclinoid aneurysms. Neurosurg Rev 34, 49–55 (2011). https://doi.org/10.1007/s10143-010-0272-7

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  • DOI: https://doi.org/10.1007/s10143-010-0272-7

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