A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms

The treatment of giant and large paraclinoid aneurysms remains challenging. To improve exposure, facilitate the dissection of aneurysms, assure vascular control, reduce brain retraction and temporary occlusion time, enable simultaneous treatment of associated lesions, and achieve more successful treatment of "difficult" (atherosclerotic and calcified) aneurysms, we combined the skull-base approach with endovascular balloon occlusion of the internal carotid artery (ICA) and suction decompression of the aneurysm.

Sixteen female patients were treated, eight with giant aneurysms and eight with large aneurysms. Eight aneurysms occurred on the right side and eight on the left. Eight patients had an additional aneurysm; five were clipped during the same procedure. Three patients had infundibular arterial dilation. One patient had an associated hemangioma of the ipsilateral cavernous sinus. The cranio-orbital-zygomatic approach was used for all patients. The anterior clinoid was drilled, and the optic nerve was decompressed, dissected, and mobilized. Transfemoral temporary balloon occlusion of the ICA in the neck was followed by placement of a temporary clip proximal to the posterior communicating artery. Suction decompression was then applied. All aneurysms were then successfully clipped, except one that had a calcified neck and wall that could not be collapsed. Intraoperative angiography performed in 13 of 15 patients with clipped aneurysms confirmed obliteration of the aneurysm and patency of the blood vessels.

Postoperative results were good in 14 patients. One patient had right-sided hemiplegia and expressive aphasia, which improved after rehabilitation. One patient with an additional basilar tip aneurysm clipped simultaneously died on the fifth postoperative day because of intraventricular hemorrhage. The origin of bleeding could not be determined on autopsy. Surgical difficulties and morbidity stemmed mainly from a severely calcified or atherosclerotic aneurysmal neck.

The combination of skull-base approaches and endovascular balloon occlusion coupled with suction decompression is a successful option for the treatment of these challenging aneurysms.