Carotid cave aneurysms of the internal carotid artery

In a series of 32 surgical cases of carotid-ophthalmic artery aneurysm, seven of the lesions were located in the "carotid cave." This special type of aneurysm is usually small and projects medially on the anteroposterior view of the angiogram. At surgery, it is located intradurally at the dural penetration of the internal carotid artery (ICA) on the ventromedial side, appears to be buried in the dural pouch (carotid cave), and is often difficult to find, dissect, and clip. The aneurysm extends into the cavernous sinus space, and the parent ICA penetrates the dural ring obliquely. An ipsilateral pterional approach was used in all 32 cases, and ring clips were used exclusively because the aneurysms were located ventromedially. Clipping was successful in five cases. All patients returned to their preoperative occupation, although vision worsened postoperatively in two cases. The technical steps required for successful obliteration of this aneurysm are summarized as follows: 1) exposure of the cervical ICA; 2) unroofing of the optic canal and removal of the anterior clinoid process; 3) exploration of the ICA around the dural ring and opening of the cavernous sinus; 4) direct retraction of the ICA and optic nerve; and 5) application of multiple ring clips to conform to the natural curvature of the carotid artery; a curved-blade ring clip is especially useful. The relevant topographic anatomy is discussed.