Surgical management of large and giant intracavernous and paraclinoid aneurysms
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Published on: September 8, 2023
Bai-nan Xu1, Zheng-hui Sun, Jin-li Jiang
1Department of Neurosurgery, General Hospital of People's Liberation Army, Beijing 100853, China. shjwkk@sina.com
Insights
Surgical management of large and giant intracavernous and paraclinoid aneurysms offers favorable outcomes. Key techniques like retrograde suction decompression and advanced monitoring ensure patient safety and successful treatment.
Area of Science:
- Neurosurgery
- Vascular Surgery
- Cerebrovascular Disease
Background:
- Large and giant intracavernous and paraclinoid aneurysms pose significant surgical challenges.
- This study reviews the characteristics, indications, and treatment strategies for these complex aneurysms in 36 patients.
Purpose of the Study:
- To evaluate the surgical outcomes and essential techniques for treating large and giant intracavernous and paraclinoid aneurysms.
- To establish surgical treatment as a primary option for paraclinoid aneurysms and selected intracavernous aneurysms.
Main Methods:
- The pterional approach was utilized, with cervical internal carotid artery exposure for proximal control.
- Techniques included direct clipping, pseudoaneurysm repair, and trapping with extracranial-intracranial bypass.
- Intraoperative monitoring (EEG, SSEP), Doppler ultrasonography, and endoscopy were employed for safety and efficacy.
Main Results:
- 32 paraclinoid aneurysms were clipped, 1 intracavernous pseudoaneurysm repaired, and 3 intracavernous aneurysms trapped with revascularization.
- Postoperative outcomes were favorable, with 32/34 patients achieving good recovery (Rankin 0-2) at 6 months.
- Monitoring led to clip readjustments in 12 cases, optimizing blood flow.
Conclusions:
- Surgical intervention is the preferred treatment for paraclinoid aneurysms and intracavernous aneurysms unsuitable for endovascular methods.
- Essential surgical techniques include parent vessel occlusion, decompression, endoaneurysmectomy, and advanced monitoring.
- This approach ensures safe and effective management of complex intracavernous and paraclinoid aneurysms.
Background:
Due to their location, large and giant intracavernous and paraclinoid aneurysms remain a challenge for vascular neurosurgeons. We identified characteristics, surgical indications and treatment strategies of large and giant intracavernous and paraclinoid aneurysms in 36 patients.
Methods:
The pterional approach was routinely used. The cervical internal carotid artery was exposed for proximal control of parent vessel and retrograde suction decompression. Paraclinoid aneurysms were directly clipped, intracavernous pseudoaneurysm was repaired and the intracavernous aneurysms were trapped with extracranial-intracranial bypass of saphenous vein graft. Intraoperative electroencephalogram (EEG) and somatosensory evoked potential (SSEP) monitoring were used to detect cerebral ischemia during the temporary occlusion of parent arteries. Microvascular Doppler ultrasonography was used to assess blood flow of the parent and branch vessels. Endoscopy was helpful particularly in dealing with internal carotid artery posterior wall aneurysms. Postoperative digital subtraction angiography (DSA) was performed in 33 of the 36 patients.
Results:
Thirty-two paraclinoid aneurysms were directly clipped, 1 intracavernous pseudoaneurysm was repaired and the other 3 intracavernous aneurysms were trapped with revascularization. Except for two patients who died in the early postoperative stage, 34 patients' follow-up was 6 - 65 months (mean 10 months) and a Glasgow Outcome Scale score of 4 to 5 at discharge. At the 6-month follow-up examination, Rankin Outcome Scale scores were 0 to 2 in 32 patients. EEG and SSEP monitoring changed in six patients. Twelve clips were readjusted when insufficient blood flow in parent and branch vessels was detected. Three posterior wall aneurysms were clipped.
Conclusions:
Intracavernous aneurysms not amenable to endovascular treatment should be treated surgically and surgical treatment is the first option for paraclinoid aneurysms. The temporary parent vessel occlusion, retrograde suction decompression, endoaneurysmectomy, parent vessel reconstruction, vascular anastomosis, electrophysiological monitoring, Doppler ultrasonography and endoscopy are essential techniques in the treatment of the large and giant intracavernous and paraclinoid aneurysms.
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