Bilateral ophthalmic segment aneurysm clipping with one craniotomy: operative technique and results

Surgical indications for ophthalmic segment aneurysms are getting narrower due in part to success of endovascular techniques like flow diverters. Wide necks, large size, intraluminal thrombus, optic nerve compression or recurrence after endovascular therapy make the case for surgical treatment. Bilateral aneurysms are less established but worth considering surgical indication. Our objective is to review a series of bilateral ophthalmic segment aneurysms managed through a single craniotomy, describe the surgical technique and evaluate the results.

Between 1997 and 2012, 11 patients with bilateral ophthalmic segment aneurysms were treated through a single craniotomy at UCSF Medical Center. An intradural clinoidectomy was performed to expose and clip the ipsilateral aneurysm. Medially and superiorly projecting contralateral aneurysm could be clipped through the interoptic triangle without clinoidectomy. Indocyanin green videoangiography was performed routinely.

Eleven patients harboring 22 ophthalmic segment aneurysms were treated with a single craniotomy. Complete neck occlusion was achieved in 96 % of aneurysms. One patient presenting with subarachnoid hemorrhage Hunt-Hess grade 5 died from vasospasm complications. The remaining 10 patients had good outcomes (mRS ≤ 2) after a mean 2.2 years follow up. There were no recurrences after surgical treatment.

Decompressing the optic nerve, completely occluding the aneurysm neck, providing a durable repair and avoiding antiplatelet agents are the well established advantages of microsurgical management. This experience demonstrates safety and feasibility of contralateral clipping of carefully selected ophthalmic segment aneurysms, thus pointing another advantage of surgical clipping when bilateral aneurysms are diagnosed.