Visual Outcomes after Surgery for Paraclinoid Aneurysms: A Fujita Experience

Microsurgical treatment of ophthalmic artery aneurysm, a case series of 55 patients with long-term follow-up

BACKGROUND

Ophthalmic artery aneurysm (OAA) can be secured in endovascular or microsurgical approaches. Still there are controversies in technique selection and their long term outcomes.

METHODS

All the patients with OAA were treated microsurgically and followed. Demographic data, neurological status, physical examination findings, angiographic data, operation details, and intraoperative and postoperative events were recorded and analyzed. P < 0.05 was considered significant.

RESULTS

Among 55 patients, 38 were females (69.1%). Median preoperative glasgow coma scale (GCS), Fisher Grade, and Hunt and Hess(HH) scores were 15, 1 and 1, respectively. The most common neurologic manifestation was visual problems (n = 15). The most common anatomical projection was medial (43.6%) oriented lesions. 85.5% of them only had 1 ophthalmic aneurysm while multiple aneurysms were reported in 14.6%. In 52 patients temporary clip was used. in 21 patients (38.2%) intraoperative aneurysm rupture occurred. Larger aneurysm size and preoperative hydrocephalus were associated with higher rates of aneurysm rupture (P = 0.003 and 0.031). 28.5% of the patients with visual problems had clinical improvement in the postoperative period. The mean follow-up period was 5 years. Follow-up angiography showed a 100% obliteration rate with a 0.0% recurrence rate. Median values for follow-up glasgow outcome scale and modified Rankin scale were 5 and 0, respectively. favorable neurological outcomes were associated with better primary GCS and HH scores.

CONCLUSION

OAA microsurgery is an effective and safe procedure with significant improvement in both visual and neurological status. Low recurrence rate and excellent clinical recovery are the most important advantages of microsurgery in OAA treatment.

Visual Evoked Potential Can Predict Deterioration of Visual Function After Direct Clipping of Paraclinoid Aneurysm With Anterior Clinoidectomy

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.

Extradural anterior clinoidectomy versus endoscopic transplanum-transcavernous approach to the paraclinoid region: quantitative anatomical exposure analysis

BACKGROUND

Transcranial anterior clinoidectomy is a conventional microsurgical approach for treatment of paraclinoid aneurysms. The endoscopic endonasal approach (EEA) is an alternative method for clipping intracranial aneurysms. No analysis has been conducted to anatomically compare approaches with respect to treating paraclinoid aneurysms. The surgical anatomical exposures of the paraclinoid region during transcranial extradural anterior clinoidectomy (EAC) and the endoscopic endonasal transplanum-cavernous approach (EETC) are described and quantitatively assessed.

METHOD

Seven cadaveric heads underwent EAC and EETC. Measurements included the area of exposure, volume of surgical freedom, angle of attack, ophthalmic artery (OphA) origin, and coronal exposure angle of the internal carotid artery (ICA).

RESULTS

The EETC provided a larger area of exposure than the EAC (100.1±24.9 vs 76.1±12.9 mm², p = 0.04). The EAC provided a higher volume of surgical freedom and greater angle of attack than the EETC in all neurovascular parameters, including the OphA, superior hypophyseal artery (SHA), distal ICA, and distal dural ring (all p < 0.001). The OphA origin was intradural in 85.7% and extradural in 14.3% of specimens. With regard to the coronal angle of exposure, the EAC exposed the OphA and SHA in the upper lateral quadrant (67.9±7.8° and 80.6±4.5°, respectively) and the distal ICA in the upper medial and upper lateral quadrants (92±7.5°). The EEA exposed the OphA, SHA, and distal ICA in the upper medial and lower medial quadrants (130.4±10.7°, 68.4±10.8°, and 58±11.4°, respectively).

CONCLUSIONS

The EAC and EETC each offer specific advantages for paraclinoid region exposure. The EAC is appropriate for paraclinoid aneurysms that occur at the dorsolateral surface of the paraclinoid ICA. The EETC is an alternative approach for aneurysms that occur along medial surface of the paraclinoid ICA (e.g., carotid cave and SHA aneurysms). The EETC provides greater surgical exposure to the medial aspect of the paraclinoid ICA.