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Versyck G, van Loon J, Lemmens R, Demeestere J, Bonne L, Peluso JP, De Vleeschouwer S. An overview of decision-making in cerebrovascular treatment strategies: Part I - unruptured aneurysms. BRAIN & SPINE 2024; 4:103331. [PMID: 39309547 PMCID: PMC11416541 DOI: 10.1016/j.bas.2024.103331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/28/2024] [Accepted: 09/04/2024] [Indexed: 09/25/2024]
Abstract
Introduction Unruptured intracranial aneurysm treatment has evolved over the last two centuries, starting from the introduction of aneurysm ligation and clipping, up until the inception of endovascular treatment and further advancements in both fields. Research question The wide variety of aneurysm presentations and possible treatment modalities, complicates the understanding of decision-making for the treatment of a given aneurysm. The goal of this article is to provide an overview of the best available evidence concerning unruptured intracranial aneurysm decision-making and identify insights and hiatuses, as well as providing a scaffold to surpass the subjectiveness of decision-making. Materials and methods A literature review was performed for the most impactful articles on decision-making in unruptured intracranial aneurysm treatment, to provide an overview on current practice. Results Two groups of decision-altering factors were identified; patient-related and aneurysm-related factors. A summary is presented of the general evidence, and the influence of age, aneurysmal mass-effect, as well as size, morphological aspects and specific anatomical locations on decision-making. Discussion and conclusion Decision-making for an unruptured intracranial aneurysm often comes down to combining these different patient- and aneurysm-related factors. In this paper, an evidence-based overview is provided into these different factors which alter management of unruptured saccular aneurysms.
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Affiliation(s)
- Georges Versyck
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Johannes van Loon
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Jelle Demeestere
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Lawrence Bonne
- Department of Interventional Radiology, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Jo P. Peluso
- Department of Interventional Radiology, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
| | - Steven De Vleeschouwer
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
- Neuro-vascular Unit, University Hospitals Leuven, Leuven Brain Institute (LBI), Belgium
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Rodriguez-Calienes A, Borjas-Calderón NF, Vivanco-Suarez J, Zila-Velasque JP, Chavez-Malpartida SS, Terry F, Grados-Espinoza P, Saal-Zapata G. Endovascular Treatment and Microsurgical Clipping for the Management of Paraclinoid Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 178:e489-e509. [PMID: 37516140 DOI: 10.1016/j.wneu.2023.07.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVE We aimed to compare the efficacy and safety of microsurgical clipping versus endovascular treatment (EVT) for paraclinoid aneurysms. METHODS A systematic search for studies including patients with paraclinoid aneurysms treated with a microsurgical or endovascular technique was conducted in 6 databases from inception to February 2022. Efficacy outcomes included complete angiographic occlusion at last follow-up, favorable functional outcome, and recurrence of the aneurysm. For safety, we assessed a composite of intraoperative and postoperative complications. Data were pooled using a random-effects model. RESULTS A total of 95 studies including 6711 patients, 3029 in the surgical group and 3682 in the EVT group were found. Pooled rates of complete occlusion were 94% (95% CI 91%-96%; I2 = 0%) in the surgical group and 69% (95% CI 63%-74%; I2 = 79%) in the EVT group, respectively. The favorable functional outcome rate was 86% (95% CI 76%-92%; I2 = 72%) with surgical treatment and 95% (95% CI 92%-97%; I2 = 61%) with EVT. The rate of aneurysm recurrence with surgical treatment was 1% (95% CI 0%-4%; I2 = 0%) and 12% (95% CI 9%-16%; I2 = 57%) with EVT. The composite safety outcome rate in the surgical group was 24% (95% CI 18%-30%; I2 = 90%) and 10% (95% CI 8%-13%; I2 = 71%) in the EVT group. CONCLUSIONS Our findings suggest that microsurgical clipping seems to have a higher efficacy than EVT in terms of angiographic occlusion and aneurysm recurrence; however, EVT seems to be safer in terms of intraoperative and postoperative complications. Considering the heterogeneity and low-level evidence of the data available, further prospective randomized studies are warranted to confirm our findings.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru.
| | - Nagheli Fernanda Borjas-Calderón
- Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru; Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru; Abdulrauf University of Neurosurgery, Simi Valley, California, USA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - J Pierre Zila-Velasque
- Universidad Nacional Daniel Alcides Carrión, Facultad de Medicina Humana, Pasco, Peru; Red Latinoamericana de Medicina en la Altitud e Investigación (REDLAMAI), Pasco, Peru
| | - Sandra S Chavez-Malpartida
- Universidad Nacional Mayor de San Marcos, Lima, Peru; Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | - Fernando Terry
- Department of Neurosurgery, Clínica Internacional, Lima, Peru
| | - Pamela Grados-Espinoza
- Universidad Nacional Daniel Alcides Carrión, Facultad de Medicina Humana, Pasco, Peru; Red Latinoamericana de Medicina en la Altitud e Investigación (REDLAMAI), Pasco, Peru
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru
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Kawajiri S, Isozaki M, Komori O, Yamada S, Higashino Y, Yamauchi T, Akazawa A, Kidoguchi M, Yomo M, Kodera T, Arishma H, Awara K, Inatani M, Kikuta K. Visual Evoked Potential Can Predict Deterioration of Visual Function After Direct Clipping of Paraclinoid Aneurysm With Anterior Clinoidectomy. Neurosurgery 2023; 92:1276-1286. [PMID: 36757317 DOI: 10.1227/neu.0000000000002363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/14/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND The role of visual evoked potential (VEP) in direct clipping of the paraclinoid internal carotid artery (ICA) aneurysm remains uncertain. OBJECTIVE To examine whether intraoperative neuromonitoring with VEP can predict deterioration of visual function after direct clipping of the paraclinoid ICA aneurysm with anterior clinoidectomy. METHODS Among consecutive 274 patients with unruptured cerebral aneurysm, we enrolled 25 patients with paraclinoid ICA aneurysm treated by direct clipping after anterior clinoidectomy with intraoperative neuromonitoring with VEP in this study. We evaluated the visual acuity loss (VAL) and visual field loss (VFL) before surgery, 1 month after surgery, and at the final follow-up. RESULTS The VAL at 1 month after surgery (VAL1M) and VAL at the final follow-up (Final VAL) were significantly related to the reduction rate of VEP amplitude at the end of surgery (RedEnd%), more than 76.5%, and the maximal reduction rate of VEP amplitude during surgery (MaxRed%), more than 66.7% to 70%. The VFL at 1 month after surgery (VFL1M) and the VFL at the final follow-up (Final VFL) were significantly related to MaxRed% more than 60.7%. CONCLUSION VAL1M, Final VAL, VFL1M, and Final VFL could be significantly predicted by the value of RedEnd% and MaxRed% in direct clipping of Al-Rodhan group Ia, Ib, and II paraclinoid ICA aneurysms with anterior clinoidectomy.
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Affiliation(s)
- Satoshi Kawajiri
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Makoto Isozaki
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Osamu Komori
- Department of Computer and Information Science, Faculty of Science and Technology, Seikei University, Tokyo, Japan
| | - Shinsuke Yamada
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yorhifumi Higashino
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Takahiro Yamauchi
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Ayumi Akazawa
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Masamune Kidoguchi
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Munetaka Yomo
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Toshiaki Kodera
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Hidetaka Arishma
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kousuke Awara
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Masaru Inatani
- Department of Ophthalmology, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Kenichiro Kikuta
- Department of Neurosurgery, Division of Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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Tsunoda S, Inoue T, Takeuchi N, Akabane A, Saito N. Direct Clipping of Paraclinoid Aneurysm in Conjunction with Extradural Anterior Clinoidectomy: Technical Nuance and Functional Outcome. Skull Base Surg 2022; 83:505-514. [DOI: 10.1055/s-0041-1730351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 01/07/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Objective Because of their anatomical features, treatment for paraclinoid aneurysms has remained to be challenging. Thus, the aim of this report is to prove the validity of our surgical method for unruptured paraclinoid aneurysms, together with surgical videos.
Study Design Between August 2017 and November 2019, we were able to perform surgical clipping for 11 patients with unruptured paraclinoid aneurysm using a completely unified method. This study investigated the effect of surgery on multiple measures, including visual impairment, brain contusion, temporalis muscle atrophy, and multiple neurocognitive functions.
Results Of the 67 unruptured aneurysms treated at our hospital, 17 were identified to be paraclinoid aneurysm, and 11 of them were treated by direct clipping using anterior clinoidectomy. Three were ophthalmic artery aneurysms, three were superior hypophyseal artery aneurysms, and five were anterior carotid wall aneurysms without branch projection. Only one patient had asymptomatic mild enlargement of the Marriott blind spots postoperatively. No brain contusion and temporalis muscle atrophy were observed in any cases. Only the Trail Making test (TMT) showed a significant worsening in the acute postoperative period: mean pre- and postoperative TMT scores were 59.1 ± 29.1 and 72.7 ± 37.3 for Part A (p = 0.018) and 80.5 ± 35.5 and 93.8 ± 39.9 for Part B (p = 0.030), respectively. However, it improved in the chronic phase.
Conclusion We can conclude that our surgical method is safe and can be considered an acceptable treatment. Although surgical stress can cause temporary executive dysfunction shortly after surgery, this decline is temporary.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo, Japan
| | - Naoko Takeuchi
- Department of Rehabilitation, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo, Japan
| | - Atsuya Akabane
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
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Zhou HJ, Wang XY, Zhan RY, Zheng JS, Yu JB, Zheng XJ. Clipping Ophthalmic Segment Artery Aneurysms Using a Modified Subdural Dolenc Approach: Classification and Experience Sharing. Oper Neurosurg (Hagerstown) 2022; 23:154-163. [PMID: 35838455 DOI: 10.1227/ons.0000000000000262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/03/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Ophthalmic segment artery aneurysms (OSAs) are difficult to clip; therefore, improvement of the surgical method is of great significance to the prevention of complications, and the classification of the aneurysms is essential to formulate a reasonable surgical plan. OBJECTIVE To explore the strategies and effects of surgery for OSAs using a modified subdural Dolenc approach. METHODS The clinical data of 38 patients (12 men and 26 women, aged 48-73 years) with OSA were analyzed retrospectively. A total of 44 aneurysms were identified, 40 of which were OSAs. The 40 aneurysms were divided into types Ia1 (n = 2), Ia2 (n = 2), Ib (n = 6), IIa (n = 4), IIb (n = 4), IIIa (n = 0), IIIb (n = 4), IIIc (n = 16), and IV (n = 2) based on preoperative images. Thirty-nine OSAs were operated successfully through pterional craniotomy combined with the modified subdural Dolenc approach, and 1 aneurysm was clipped through the contralateral approach. Clinical outcomes were evaluated using the Glasgow Outcome Scale (GOS). RESULTS Thirty-nine OSAs were clipped, and one was wrapped. Visual dysfunction, headache, and dizziness improved after the operation in 18 patients. One patient had new visual impairment, and there were no deaths. At discharge, the GOS score was 5 in 36 cases, 4 in 1 case, and 3 in 1 case. Thirty-seven patients had a GOS score of 5, and 1 patient had a score of 3 at 6 months after the operation. CONCLUSION The modified subdural Dolenc approach (Zheng approach) for clipping OSAs may be associated with less trauma and good postoperative outcomes.
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Affiliation(s)
- Heng-Jun Zhou
- Department of Neurosurgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Visual Impairment due to a large paraclinoid aneurysm treated with parent artery occlusion and bypass: A case report. J Stroke Cerebrovasc Dis 2022; 31:106280. [DOI: 10.1016/j.jstrokecerebrovasdis.2021.106280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/23/2021] [Accepted: 12/19/2021] [Indexed: 11/19/2022] Open
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Ota N, Petrakakis I, Noda K, Miyazaki T, Kondo T, Kinoshita Y, Kamiyama H, Tokuda S, Tanikawa R. Predictor of Visual Impairment Following Paraclinoid Aneurysm Surgery: Special Consideration of Surgical Microanatomy Related to Paraclinoid Structures. Oper Neurosurg (Hagerstown) 2020; 20:45-54. [PMID: 33047135 DOI: 10.1093/ons/opaa298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 07/11/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Microsurgical clipping with extradural anterior clinoidectomy (EDAC) for paraclinoid aneurysm is an established technique with good angiographic outcomes, although postoperative worsening of visual acuity remains a concern. Multiple reports show visual acuity deteriorating after clipping, yet the cause remains unclear. OBJECTIVE To analyze results of asymptomatic paraclinoid aneurysm surgeries treated with EDACs, specifically focusing on the microanatomy of paraclinoid structure dissection. This determined the causes of delayed visual impairment and microsurgical indications. METHODS Results of the treatment with EDAC of 94 patients with cerebral aneurysm and normal preoperative visual acuity but also full visual fields were retrospectively analyzed. RESULTS The mean aneurysm size was 6.2 (±3.3) mm. Clipping was performed in 87 cases and trapping in 7 cases. Complete angiographic occlusion was observed in 91 patients. In 26 cases, a postoperative visual deficit occurred. A total of 20 cases exhibited partial visual field deficits, including 5 who were asymptomatic. Visual deficits were only detectable by postoperative ophthalmologic testing. Six showed light perception impairment or blinding. Of the 15 patients with symptomatic partial visual field deficits, 5 showed improvement at follow-up. Visual deficits persisted in 22 patients at the last follow-up. Multivariate logistic regression analysis revealed that medial projecting aneurysm (adjusted odds ratio [OR]: 10.43) and the opening of the carotidoculomotor membrane (adjusted OR: 5.19) were significantly related to visual impairment. CONCLUSION Excess dissection of carotidoculomotor membranes causes postoperative delayed visual worsening. For treating small, asymptomatic paraclinoid aneurysms, carotidoculomotor membranes should not be opened, and microsurgical clipping should not be performed for preoperative asymptomatic medial projecting aneurysms.
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Affiliation(s)
- Nakao Ota
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Ioannis Petrakakis
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kosumo Noda
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Takanori Miyazaki
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Tomomasa Kondo
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Yu Kinoshita
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Hiroyasu Kamiyama
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Sadahisa Tokuda
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Rokuya Tanikawa
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
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Kutty RK, Kumar A, Yamada Y, Kawase T, Tanaka R, Miyatani K, Higashiguchi S, Ravishankar V, Takizawa K, Kato Y. Visual Outcomes after Surgery for Paraclinoid Aneurysms: A Fujita Experience. Asian J Neurosurg 2020; 15:363-369. [PMID: 32656133 PMCID: PMC7335145 DOI: 10.4103/ajns.ajns_39_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/06/2020] [Accepted: 02/25/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The surgical strategies for clipping of paraclinoid aneurysms are diverse. These aneurysms are unique in their location, as they closely abut the anterior clinoid process (ACP) and the optic nerve. The ultimate goal of clipping encompasses the exposure of neck of the aneurysm which is seldom complete without the manipulation of optic nerve and the ACP. This manipulation may result in disturbances of vision postoperatively. We analyze our results of visual outcomes in the surgery for paraclinoid aneurysms in this retrospective study. MATERIALS AND METHODS All patients with paraclinoid aneurysms who underwent surgery from June 2014 to June 2019 were included in the study. Surgical procedure was uniform in all patients which included anterior clinoidectomy and clipping of aneurysms as per the Bantane protocol. Glasgow Outcome Scale as well as vision was assessed at discharge and at 1 month and 6 months. RESULTS There were 77 cases of paraclinoid aneurysms operated during the abovementioned period. All patients had no symptoms related to vision preoperatively. Visual deterioration was noted in two patients. All patients were discharged with a good outcome on the Glasgow Outcome Scale. CONCLUSION Paraclinoid aneurysm has a good outcome when treated with surgery. The visual deterioration following surgery can be minimized with extradural anterior clinoidectomy and careful handling of the vessels and nerve.
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Affiliation(s)
- Raja K. Kutty
- Department of Neurosurgery, Government Medical College, Trivandrum, Kerala, India
| | - Ambuj Kumar
- Department of Neurosurgery, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Yasuhiro Yamada
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Otobashi, Nagoya, Japan
| | - Tsukosa Kawase
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Otobashi, Nagoya, Japan
| | - Riki Tanaka
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Otobashi, Nagoya, Japan
| | - Kyosuke Miyatani
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Otobashi, Nagoya, Japan
| | - Saeko Higashiguchi
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Otobashi, Nagoya, Japan
| | - Vigneswar Ravishankar
- Department of Neurosurgery, Institute of Neurosciences and Spinal Disorders, MGM Healthcare, Chennai, Tamil Nadu, India
| | - Katsumi Takizawa
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, Hokkaido, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Otobashi, Nagoya, Japan
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Otani N, Mori K, Wada K, Tomiyama A, Toyooka T, Takeuchi S, Nakao Y, Yamamoto T, Arai H. Limited Indications for Clipping Surgery of Paraclinoid Aneurysm Based on Long-Term Visual Morbidity. World Neurosurg 2019; 134:e153-e161. [PMID: 31629143 DOI: 10.1016/j.wneu.2019.09.147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Clipping of paraclinoid aneurysm is still challenging because of poor visual morbidity. The extradural temporopolar approach was applied to clip paraclinoid aneurysms, with the expectation of reducing visual morbidity. Factors related to poor visual morbidity were evaluated, to assess the results for clipping of paraclinoid aneurysms. METHODS A series of 40 unruptured paraclinoid aneurysms in 38 patients were clipped via extradural temporopolar approach. Preoperative and postoperative states of visual cognitive function and radiological outcomes were investigated. Aneurysms were classified into dorsal type or non-dorsal type, and small (<9 mm) or not-small (≥9 mm), respectively, to identify factors correlated with visual morbidity. RESULTS Complete clipping rate was 90.0% without any recurrence (mean: 5.2 years). Visual morbidity was unexpectedly high at 28.9%, including 2.7% of blindness immediately after the operation, and 23.7% and 2.7% at the final examination (mean: 3.6 years). Multivariate analysis showed aneurysm size was significantly correlated with worse visual outcome. Visual morbidity was 13.3% and 11.1% for dorsal and the non-dorsal small aneurysms, respectively, and all these cases showed visual field defect limited to the nasal quadrant without decreased visual acuity. In contrast, the non-dorsal not-small aneurysms showed significantly worse visual morbidity (60%) with decreased visual acuity. CONCLUSIONS Clipping via extradural temporopolar approach can achieve durable treatment for small unruptured paraclinoid aneurysms with acceptable visual morbidity. Visual morbidity of the not-small non-dorsal type, however, was poor. The indications for clipping of paraclinoid aneurysm should be limited to small aneurysms, especially the dorsal type in young patients.
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Affiliation(s)
- Naoki Otani
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan.
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan; Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Arata Tomiyama
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Terushige Toyooka
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Hospital, Tokyo, Japan
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