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Zeng C, Wang J. Risk factors for intraoperative in-stent thrombosis during stent-assisted coiling of paraclinoid aneurysms. Front Neurol 2024; 14:1333075. [PMID: 38283676 PMCID: PMC10811721 DOI: 10.3389/fneur.2023.1333075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 12/26/2023] [Indexed: 01/30/2024] Open
Abstract
Objectives To identify independent risk factors for intraoperative in-stent thrombosis (IST) in paraclinoid aneurysms (PAs). Methods 172 PA patents undergoing stent-assisted coiling (SAC) were divided into an IST group (n = 12) and a non-IST group (n = 160). Clinical characteristics, aneurysm morphologies, and laboratory parameters were measured. We performed independent t tests (for normally distributed data) or non-parametric tests (for non-normally distributed data) to compare continuous parameters. Multivariate logistic regression analysis with a stepwise forward method was conducted to determine independent risk factors. Receiver operating characteristic curves were generated, and the Delong test was employed for comparisons. Results Independent risk factors for IST included size ratio (SR) (p < 0.001, odds ratio [OR] = 3.909, confidence interval [CI] = 1.925-7.939), adenosine diphosphate (ADP) inhibition (p = 0.028, OR = 0.967, CI = 0.938-0.996), and reaction time (R) (p = 0.006, OR = 0.326, CI = 0.147-0.725). The combined factors (SR, ADP inhibition, and R) exhibited area under the curves of 0.870, 0.720, 0.716, and 0.697, with cutoff values of 2.46, 69.90%, and 4.65, respectively. Conclusion The SR, ADP inhibition, and R values were independent risk factors for the IST in the PAs undergoing SAC. For PAs with a large SR, surgeons could prepare for long-term dual antiplatelet therapy before SAC.
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Affiliation(s)
- Chun Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Wang
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
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2
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Bocanegra-Becerra JE, Koester SW, Batista S, Perret CM, Bertani R. Clipping of Bilateral Ophthalmic Artery Aneurysms Through a Single Craniotomy. Cureus 2023; 15:e47291. [PMID: 38021998 PMCID: PMC10659564 DOI: 10.7759/cureus.47291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Bilateral ophthalmic aneurysms are rare and involve two aneurysms in the ophthalmic arteries, one on each, leading to potential symptoms such as vision loss and headaches. The treatment options for aneurysms, ranging from surgery and endovascular embolization to observation, depend on various factors, including aneurysm size and the patient's health. Microsurgery, while presenting complexities due to the intricate anatomy of the anterior clinoid region, offers potential advantages such as enhanced decompression rates and reduced aneurysm recurrence. The presented surgical video illustrates the treatment of bilateral ophthalmic artery aneurysms via a single craniotomy. This method reduces surgical duration and trauma, facilitating quicker patient recovery. However, this method bears potential risks, especially to both optic nerves. As underscored in the video, the utmost anatomical understanding in the anterior clinoid area is pivotal for successful outcomes and reduced complications.
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Affiliation(s)
| | - Stefan W Koester
- Medical School, Vanderbilt University School of Medicine, Nashville, USA
| | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, BRA
| | - Caio M Perret
- Neurological Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, BRA
- Neuroscience, Federal University of Rio de Janeiro, Rio de Janeiro, BRA
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Gu Y, Zhong X, Gao Y, He L. Endoscopic endonasal approach for simultaneously treating a pituitary adenoma coexisting with a paraclinoid aneurysm: illustrative case. J Neurosurg Case Lessons 2022; 3:CASE22130. [PMID: 35733842 PMCID: PMC9210266 DOI: 10.3171/case22130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/15/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is a certain incidence of pituitary adenomas coexisting with intracranial aneurysms, but a concurrent therapeutic strategy of tumor removal and aneurysm clipping via endoscopic endonasal approach is rarely reported. The indications and limitations of endoscopic endonasal approach surgery for this type of lesions are worth discussing. OBSERVATIONS The case of a pituitary tumor coexisting with a paraclinoid aneurysm was reviewed. Using an endoscopic endonasal approach, the pituitary adenoma was completely excised with extrapseudocapsular separation technique, the aneurysm was clipped at the same time, and the skull base defect was reconstructed in multilayer fashion. No tumor recurrence was found, and aneurysm clipping was complete at the 6-month follow-up after surgery. LESSONS For patients harboring a pituitary adenoma with a selected paraclinoid aneurysm, simultaneous tumor resection and aneurysm clipping via endoscopic endonasal approach are feasible. This strategy has the advantages of saving medical resources, promoting the patient’s rapid postoperative recovery, and reducing possible antiplatelet therapy after interventional therapy. However, surgery needs to strictly follow the indications in experienced hands, and the therapeutic effect needs to be verified by more cases and longer follow-up results.
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Affiliation(s)
- Ye Gu
- Department of Neurosurgery and Otolaryngology, Eye & ENT Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Key Laboratory of Medical Imaging Computing and Computer Assisted Intervention, Fudan University, Shanghai, People's Republic of China; and
| | - Xiangping Zhong
- Department of Neurosurgery, Yongzhou Central Hospital, Yongzhou City, Hunan Province, People's Republic of China
| | - Yikuan Gao
- Department of Neurosurgery, Yongzhou Central Hospital, Yongzhou City, Hunan Province, People's Republic of China
| | - Lijin He
- Department of Neurosurgery, Yongzhou Central Hospital, Yongzhou City, Hunan Province, People's Republic of China
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4
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Liu S, Jin Y, Wang X, Zhang Y, Jiang L, Li G, Zhao X, Jiang T. Increased Carotid Siphon Tortuosity Is a Risk Factor for Paraclinoid Aneurysms. Front Neurol 2022; 13:869459. [PMID: 35620791 PMCID: PMC9127410 DOI: 10.3389/fneur.2022.869459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Geometrical factors associated with the surrounding vasculature can affect the risk of aneurysm formation. The aim of this study was to determine the association between carotid siphon curvature and the formation and development of paraclinoid aneurysms of the internal carotid artery. Methods Digital subtraction angiography (DSA) data from 42 patients with paraclinoid aneurysms (31 with non-aneurysmal contralateral sides) and 42 age- and gender-matched healthy controls were analyzed, retrospectively. Morphological characteristics of the carotid siphon [the posterior angle (α), anterior angle (β), and Clinoid@Ophthalmic angle (γ)] were explored via three-dimensional rotational angiography (3D RA) multiplanar reconstruction. The association between carotid siphon morphology and the formation of paraclinoid aneurysms was assessed through univariate analysis. After this, logistic regression analysis was performed to identify independent risk factors for aneurysms. Results Significantly smaller α, β, and γ angles were reported in the aneurysmal carotid siphon group when compared with the non-aneurysmal contralateral healthy controls. The β angle was best for discriminating between aneurysmal and non-aneurysmal carotid siphons, with an optimal threshold of 18.25°. By adjusting for hypertension, smoking habit, hyperlipidemia, and diabetes mellitus, logistic regression analysis demonstrated an independent association between the carotid siphons angles α [odds ratio (OR) 0.953; P < 0.05], β (OR 0.690; P < 0.001), and γ (OR 0.958; P < 0.01) with the risk of paraclinoid aneurysms. Conclusions The present findings provide evidence for the importance of morphological carotid siphon variations and the likelihood of paraclinoid aneurysms. These practical morphological parameters specific to paraclinoid aneurysms are easy to assess and may aid in risk assessment in these patients.
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Affiliation(s)
- Shilin Liu
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yu Jin
- Department of Neurology, Bozhou City Peoples Hospital, Bozhou, China
| | - Xukou Wang
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yang Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Luwei Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Guanqing Li
- Department of Neurology, Bozhou City Peoples Hospital, Bozhou, China
| | - Xi Zhao
- Philips Healthcare China, Shanghai, China
| | - Tao Jiang
- Department of Neurosurgery, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Anhui Provincial Institute of Translational Medicine, Hefei, China
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Das KK, Srivastava AK, Bhaisora KS, Jaiswal AK, Behari S. Hybrid Anterior Clinoidectomy in the Clipping of Paraclinoid Aneurysms: Technique, Utility and Case Illustration. Neurol India 2022; 70:504-509. [PMID: 35532610 DOI: 10.4103/0028-3886.344615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Anterior clinoidectomy for aneurysm clipping is generally performed intradurally. Despite obvious advantages, accidental drill slippage or indirect damage from heat and bone dust remain major drawbacks. OBJECTIVE To demonstrate the surgical technique and utility of a combined extra- and intra-dural clinoidectomy in the clipping of dorsal wall paraclinoid internal carotid artery aneurysm. MATERIAL AND METHODS A case of dorsal wall paraclinoid aneurysm which was stuck to the anterior clinoid process on preoperative angiogram is presented. The surgical technique is shown stepwise, and the intricacies of the technique are described. RESULTS The hybrid clinoidectomy allowed for proper delineation of the aneurysm, mobilization of the optic nerve and intracranial proximal control on the clinoidal segment by dint of "apparent" intracranial ICA lengthening. This allowed the aneurysm to be clipped successfully and the patient made an uneventful recovery. CONCLUSION Hybrid clinoidectomy is a useful technique and must be learnt.
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Affiliation(s)
- Kuntal Kanti Das
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
| | | | | | | | - Sanjay Behari
- Department of Neurosurgery, SGPGIMS, Lucknow, Uttar Pradesh, India
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Ichinose T, Misaki K, Uchiyama N, Kamide T, Nambu I, Yoshikawa A, Tsuchiya S, Nakada M. Late complications of visual impairment and hydrocephalus after flow diverter-assisted coil embolisation for intracranial large aneurysm: a case report and literature review. Br J Neurosurg 2022:1-5. [PMID: 35015601 DOI: 10.1080/02688697.2021.2024502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 12/01/2021] [Accepted: 12/27/2021] [Indexed: 11/02/2022]
Abstract
Large or giant paraclinoid aneurysms typically have good indication for flow diverter (FD) treatment. Here, we report a very rare case of a patient with an unruptured supraclinoid large aneurysm who underwent FD deployment with coil embolisation that resulted in delayed visual field defect (VFD) and hydrocephalus. A 75-year-old woman with a large right supraclinoid aneurysm presented with severe hemianopia in the right eye. She underwent FD deployment with coil embolisation of the aneurysm. However, permanent left visual field loss occurred four months after surgery. Magnetic resonance imaging (MRI) showed severe oedema surrounding the aneurysm along the optic tract. Inflammation led to postoperative hydrocephalus, requiring ventriculoperitoneal shunt placement. To the best of our knowledge, this is the first report of both a delayed VFD and hydrocephalus following FD treatment. In cases of FD treatment with coil embolisation for large paraclinoid aneurysms, clinicians should keep in mind that postoperative visual impairment or/and hydrocephalus may occur.
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Affiliation(s)
- Toshiya Ichinose
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Kouichi Misaki
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Naoyuki Uchiyama
- Department of Neurosurgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Tomoya Kamide
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | - Iku Nambu
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
| | | | - Shunsuke Tsuchiya
- Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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7
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Behari S, Dikshit P, Singh S, Singh G, Singh V, Phadke RV, Bhaisora KS. Paraclinoid Segment Aneurysms of the Internal Carotid Artery: Surgical Clipping. Neurol India 2021; 69:1184-1195. [PMID: 34747782 DOI: 10.4103/0028-3886.329547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Paraclinoid segment aneurysms arise from the internal carotid artery (ICA) between the distal dural ring and the origin of the posterior communicating (PComm) artery. Objective This pictorial study presents videos showing clipping of paraclinoid segment aneurysms. Materials and Methods The various subtypes of these aneurysms, the nuances in the technique of clinoidectomy, and methods of proximal control are presented. Results Cavernous ICA is designated as C4, clinoidal segment (between the proximal and distal dural rings) as C5, and supraclinoid segment (between the distal dural ring up to the PComm artery as C6 segment. The techniques used for clipping various aneurysms are based upon their subtypes and location. In the first case, in a giant superior hypophyseal artery aneurysm directed toward the suprasellar region, an intradural clinoidectomy helped in accessing the neck of the aneurysm encroaching into the clinoidal segment of ICA. In the second case, concurrent bilateral "kissing" paraclinoid segment aneurysms were clipped using a unilateral approach. In the third case, clipping of a dissecting paraclinoid segment aneurysm is demonstrated. Conclusions Surgery still represents the most definitive form of treatment. It may also be used to evacuate an intracerebral hematoma, with an extremely tortuous proximal vessel or in an aneurysm with complex anatomy, with blister aneurysms, or following aneurysm regrowth following a failed endovascular procedure. Assessing the three-dimensional anatomy of various segments of ICA is an important step.
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Affiliation(s)
- Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Priyadarshi Dikshit
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Suyash Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Gagandeep Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vivek Singh
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajendra V Phadke
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh S Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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8
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Sugiyama N, Fujii T, Yatomi K, Teranishi K, Oishi H, Arai H. Endovascular Treatment for Lateral Wall Paraclinoid Aneurysms and the Influence of Internal Carotid Artery Angle. Neurol Med Chir (Tokyo) 2021; 61:275-283. [PMID: 33716235 PMCID: PMC8048120 DOI: 10.2176/nmc.oa.2020-0307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Lateral wall paraclinoid aneurysms (LPA) are a rare type of aneurysm located on the lesser curve side of the internal carotid artery (ICA) bend, at the level of the anterior clinoid process. The objective of this study was to assess the influence of flexion of the ICA on the morphology of aneurysms and outcome of endovascular treatment. Between 2003 and 2018, we treated 643 cases of unruptured paraclinoid aneurysms with endovascular therapy in our institution. Of those cases, aneurysms projecting laterally on preoperative angiography were defined as LPA. The degree of bending of the ICA (ICA angle) was measured and statistically analyzed in relation to the aneurysm characteristics and the occlusion status after treatment. In all, 43 aneurysms were identified. ICA angle was positively correlated with the maximum dome size of the aneurysm (P <0.01) and the aspect ratio (P <0.01), and negatively correlated with the volume coil embolization ratio (P <0.01). Complete occlusion (CO) was achieved in 23 cases (53.5%) immediately after treatment, and in 35 cases (81.4%) at follow-up. The mean ICA angle in the incomplete occlusion group was significantly larger than in the CO group (P = 0.01). Larger ICA angle resulted in recurrence, whereas smaller ICA angle was more likely to obtain progressive thrombosis (P = 0.02). Endovascular treatment for LPA was safe and effective. The degree of flexion of the ICA may contribute to the level of hemodynamic stress on the aneurysm, its morphology, and the embolization effect.
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Affiliation(s)
- Natsuki Sugiyama
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Kosuke Teranishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine.,Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University Faculty of Medicine
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9
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Matsumoto H, Nishiyama H, Izawa D, Toki N. Simple and Reproducible Microcatheter Shaping Method for Coil Embolization of Medially-directed Paraclinoid Internal Carotid Artery Aneurysms. J Neuroendovasc Ther 2020; 14:119-125. [PMID: 37520175 PMCID: PMC10374367 DOI: 10.5797/jnet.oa.2019-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 01/29/2020] [Indexed: 08/01/2023]
Abstract
Objective It is important to guarantee intra-aneurysmal stability of microcatheters during coil embolization. We developed a simple and reproducible microcatheter shaping method for medially-directed paraclinoid internal carotid artery aneurysms. Methods An injection needle cap was used to make a smooth curve on the mandrel, which was first wound around the back end of the cap to create a primary curve. Next, a secondary curve was created using near the tip of the cap. Thus, a two-dimensional (2D), pigtail-shaped mandrel with a two-stage curve was created. The pigtail-shaped mandrel was inserted from the tip of a straight microcatheter and heat-shaped using a heat gun. Lastly, a microcatheter having a curve whose tip was approximately 6 mm longer than that of the preshaped J was created. We evaluated the ease of navigating the microcatheter into the aneurysm and its stability during coil embolization. Results In all, 34 consecutive medially-directed paraclinoid internal carotid artery aneurysms were treated using the shaped catheters. It took 50-300 seconds (intermediate value: 90 seconds) from inserting the microcatheter with a microguide wire to navigate and place it into an aneurysm. There were no cases that required reshaping of the microcatheters during navigation into the aneurysm. There were no cases that resulted in kickback of the microcatheters from the aneurysm during coil placement, and microcatheter stability was good until the end of the procedure. In all, 12 cases required the balloon-assisted technique and three cases required stent-assisted coiling. The angiographic outcomes immediately after embolization were as follows: 25 cases (73.5%) with complete occlusion; 3 cases (8.8%) with dome filling; and 6 cases (17.6%) with a neck remnant. There were no perioperative complications. Conclusion The shaping method with a pigtail-shaped mandrel using an injection needle cap is simple and reproducible, and is useful for medially-directed paraclinoid internal carotid artery aneurysms.
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Affiliation(s)
- Hiroyuki Matsumoto
- Department of Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Hirokazu Nishiyama
- Department of Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Daisuke Izawa
- Department of Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Naotsugu Toki
- Department of Neurological Surgery, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
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10
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Szmuda T, Słoniewski P, Ali S, Kamieniecki A, Dzierżanowski J. Extent of anterior clinoidectomy for clipping of carotid-ophthalmic aneurysms predicted on three-dimensional computerised tomography angiography. Neurol Neurochir Pol 2020; 54:138-149. [PMID: 32101325 DOI: 10.5603/pjnns.a2020.0017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/29/2019] [Accepted: 01/22/2020] [Indexed: 11/25/2022]
Abstract
AIM OF STUDY We aimed to verify the value of computerised tomography angiography (CTA) on predicting the extent of anterior clinoidectomy that is optimal for particular carotid-ophthalmic aneurysms (COAs). CLINICAL RATIONALE FOR STUDY The anterior clinoid process (ACP) often impedes the complex microsurgery of COA. Complete removal of the ACP ensures safe clipping; however, it also may increase the risk of severe complications. The probability of performing a successful partial anterior clinoidectomy could be evaluated by preoperative CTA. MATERIALS AND METHODS 28 patients with either a ruptured (n=4) or unruptured COA were included in this prospective, single-centre, observational study. One aneurysm was giant, two were large, and the rest were smaller. Successful aneurysm clipping was the aim in all cases. The anterior clinoidectomy was preoperatively planned on multiplanar three-dimensional reconstructions of CTA images (3D-CTA) which resembled the typical view of a frontotemporal craniotomy. Finally, the predicted clinoidectomy was compared to the extent of the actual clinoidectomy. RESULTS 21 aneurysms (75%) projected superolateral or superior. The ACP was completely and selectively resected in 25% (7 of 28) and 67.9% of patients (19 of 28) respectively. Optic nerve (ON) unroofing was always performed in the case of total anterior clinoidectomy, but accompanied only 8 of 19 selective clinoidectomies (p = 0.03). The extent of the actual clinoidectomy was predicted by the 3D-CTA-based preoperative planning in 17 of 27 cases (63.0%). Particularly, prediction of the osteotomy was correct in 85.7% of complete, 62.5% of selective lateral, and 57.1% of medial clinoidectomy. None of the radiological and clinical factors determined the correlation between the planned and the actual extent of ACP removal. There was one incomplete occlusion among 23 obtained follow-up CTAs. CONCLUSIONS The predictive value of 3D-CTA on the extent of anterior clinoidectomy still remains unsatisfactory; it is limited by the individual variability of COA and its surrounding structures. CLINICAL IMPLICATIONS Currently, the role of 3D-CTA planning is restricted to educational purposes only.
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Affiliation(s)
- Tomasz Szmuda
- Neurosurgery Department, Medical University of Gdansk, Poland.. .,Student's Scientific Circle, Neurosurgery Department, Medical University of Gdansk, Poland..
| | | | - Shan Ali
- Student's Scientific Circle, Neurosurgery Department, Medical University of Gdansk, Poland
| | - Alexandra Kamieniecki
- Student's Scientific Circle, Neurosurgery Department, Medical University of Gdansk, Poland
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11
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Tayebi Meybodi A, Borba Moreira L, Lawton MT, Eschbacher JM, Belykh EG, Felicella MM, Preul MC. Interdural course of the ophthalmic artery in the optic canal. J Neurosurg 2019; 132:277-283. [PMID: 30611145 DOI: 10.3171/2018.6.jns18856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the current neurosurgical and anatomical literature, the intracanalicular segment of the ophthalmic artery (OphA) is usually described to be within the optic nerve dural sheath (ONDS), implying direct contact between the nerve and the artery inside the optic canal. In the present study, the authors sought to clarify the exact relationship between the OphA and ONDS. METHODS Ten cadaveric heads were subjected to endoscopic endonasal and transcranial exposures of the OphA in the optic canal (5 for each approach). The relationship between the OphA and ONDS was assessed. Histological examination of one specimen of the optic nerve and the accompanying OphA was also performed to confirm the relationship with the ONDS. RESULTS In all specimens, the OphA coursed between the two layers of the dura (endosteal and meningeal) and was not in direct contact with the optic nerve, except for the first few millimeters of the proximal optic canal before it pierced the ONDS. Upon reaching the orbit, the two layers of the dura separated and allowed the OphA to literally float within the orbital fat. The meningeal dura continued as the ONDS, whereas the endosteal dura became the periorbita. CONCLUSIONS This study clarifies the interdural course of the OphA within the optic canal. This anatomical nuance has important neurosurgical implications regarding safe exposure and manipulation of the OphA.
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Affiliation(s)
| | | | | | - Jennifer M Eschbacher
- 2Department of Neuropathology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Michelle M Felicella
- 2Department of Neuropathology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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12
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Otani N, Toyooka T, Takeuchi S, Tomiyama A, Nakao Y, Yamamoto T, Wada K, Mori K. Less Invasive Modified Extradural Temporopolar Approach for Paraclinoid Lesions: Operative Technique and Surgical Results in 80 Consecutive Patients. Skull Base Surg 2018; 79:S347-S355. [PMID: 30210989 DOI: 10.1055/s-0038-1654703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 03/31/2018] [Indexed: 10/16/2022]
Abstract
Background Extradural temporopolar approach for paraclinoid lesions can provide extensive and early exposure of the anterior clinoid process, and complete mobilization and decompression of the optic nerve and internal carotid artery, which can prevent intraoperative neurovascular injury. The present study investigated the usefulness of our less invasive modified technique and discussed its operative nuances. Methods We retrospectively reviewed medical charts of 80 consecutive patients with neoplastic (21 patients) and vascular lesions (59 patients) who underwent the modified extradural temporopolar approach between September 2009 and March 2014. Results Preoperative visual acuity worsened in 4 patients (5.0%) and worsening of visual field function occurred in 10 patients (12.5%). Postoperative outcome was good recovery in 71 patients, moderate disability in 6, severe disability in 2, and death in 1 (due to reruptured aneurysm). No operation-related mortality occurred in the series. Conclusion Less invasive modified extradural temporopolar approach is safe and can be recommended for the surgical treatment of deeply located aneurysms and skull base tumors to reduce the risk of intraoperative optic neurovascular injury.
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Affiliation(s)
- Naoki Otani
- 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
| | - Arata Tomiyama
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Shizuoka Prefecture, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Shizuoka Prefecture, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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13
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Choque-Velasquez J, Hernesniemi J. Anterior clinoidectomy for paraclinoid aneurysms in Helsinki Neurosurgery. Surg Neurol Int 2018; 9:185. [PMID: 30283718 PMCID: PMC6157036 DOI: 10.4103/sni.sni_261_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 08/09/2018] [Indexed: 11/18/2022] Open
Abstract
Background: In this video abstract, we present an intradural anterior clinoidectomy for management of some paraclinoid aneurysms. Quick adenosine cardiac arrest performed instead of an anterior clinoidectomy and proximal temporary clipping usually allows us a proximal control of aneurysms in Helsinki Neurosurgery. However, when the neck of the aneurysm remains hidden under the anterior clinoid process, or when some complex aneurysms have reduced space for placing temporary clips obstructing the definitive clipping, anterior clinoidectomy is the most available option. Technique: The patient with multiple intracranial aneurysms had a ruptured anterior cerebral artery aneurysm associated with a right middle cerebral artery aneurysm and a right small paraclinoid aneurysm. The patient underwent surgical clipping of all aneurysms by a right lateral supraorbital approach at one-stage surgery. After the associated aneurysms were clipped, the hidden paraclinoid aneurysm required an anterior clinoidectomy for definitive clipping. A small durotomy over the anterior clinoid process was made with microscissors after bipolar coagulation. Subsequently, the anterior clinoidectomy was performed under visual control with the use of an electric high-speed diamond drill (3 mm diameter). The direction and size of the drilling were performed according to the anatomical configuration and exact location of the aneurysm determined by the preoperative radiological analysis of the case. A definitive clip was applied after complete visualization of aneurysm. Postoperative computed tomography angiography demonstrated absence of complications. Conclusion: Anterior clinoidectomy is a useful procedure aiming at a proper definitive clipping of paraclinoid aneurysms with challenging locations and configurations. Videolink: http://surgicalneurologyint.com/videogallery/right-clinoidectomy/
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Affiliation(s)
| | - Juha Hernesniemi
- International Center for Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
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14
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Otani N, Wada K, Toyoka T, Mori K. Suction Decompression during Anterior Clinoidectomy for Direct Clipping of Paraclinoid Aneurysm Involving the Anterior Clinoid Process. Asian J Neurosurg 2018; 13:482-484. [PMID: 29682067 PMCID: PMC5898138 DOI: 10.4103/ajns.ajns_153_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Surgical clipping of paraclinoid aneurysms involving the anterior clinoid process (ACP) can present great challenges because strong adhesion may hinder dissection of the surrounding anatomical structures from the aneurysm dome. On the other hand, retrograde suction decompression (RSD) through direct puncture of the common carotid artery is a useful adjunct technique for clipping of these aneurysms. The present case illustrates that direct clipping of paraclinoid aneurysms involving the ACP can be achieved safely and less invasively using RSD during anterior clinoidectomy. Postoperatively, her clinical course was uneventful. RSD is a useful technique during anterior clinoidectomy in direct clipping of paraclinoid aneurysms involving the ACP.
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Affiliation(s)
- Naoki Otani
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Terushige Toyoka
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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15
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Otani N, Toyooka T, Wada K, Mori K. Modified extradural temporopolar approach with suction decompression for clipping of large paraclinoid aneurysm: Technical note. Surg Neurol Int 2017; 8:148. [PMID: 28791191 PMCID: PMC5525458 DOI: 10.4103/sni.sni_377_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/26/2017] [Indexed: 12/02/2022] Open
Abstract
Background: Surgical clipping of complicated large paraclinoid aneurysms are still challenging because strong adhesion of aneurysm itself may hinder the dissection of the perforators and the surrounding anatomical structures from the aneurysm dome. Methods: We describe 13 consecutive patients and the clipping of complicated, large-sized paraclinoid aneurysms using a modified extradural temporopolar approach combined with retrograde suction decompression and discuss its advantages and pitfalls. Results: Modified extradural temporopolar approach with suction decompression (SD) assistance was performed in all patients. There was no complication related to the surgical procedure. Postoperative outcome was good recovery in 7 patients, moderate disability in 4, and severe disability in 2 caused by severe subarachnoid hemorrhage. Favorable outcomes were achieved in 10 patients (84.6%). Conclusion: We recommend its less invasive, safe, and useful combined technique in the treatment of symptomatic paraclinoid aneurysms, which carry the risk of neurovascular injury caused by dissection from the aneurysm dome.
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Affiliation(s)
- Naoki Otani
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Terushige Toyooka
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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16
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Zdilla MJ, Cyrus LM, Lambert HW. Carotico-clinoid foramina and a double optic canal: A case report with neurosurgical implications. Surg Neurol Int 2015; 6:13. [PMID: 25657866 PMCID: PMC4314831 DOI: 10.4103/2152-7806.150456] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 11/12/2014] [Indexed: 12/01/2022] Open
Abstract
Background: The lesser wing of the sphenoid is a clinically important structure, particularly with regard to its anatomical relationship with neurovascular structures including the optic nerve, ophthalmic artery, and internal carotid artery. Anterior clinoidectomy, a neurosurgical procedure utilized to access paraclinoid aneurysms and neoplasms, is often complicated by the presence of anatomical variants including the carotico-clinoid foramen and the accessory optic canal. Case Description: A rare case report is presented documenting the simultaneous occurrence of bilateral carotico-clinoid foramina and a unilateral accessory optic canal. Conclusion: The presence of an accessory optic canal may be misconstrued as a carotico-clinoid foramen or pneumatization of the anterior clinoid process, lesser sphenoidal wing, or optic strut. The case report documents two clinically important variant structures occurring ipsilaterally, each with the potential to masquerade as the other radiographically and present complications to both neurosurgeons and radiologists. Knowledge of the unique combination of anatomical variants presented in this report may prevent adverse surgical events during anterior clinoidectomy procedures including hemorrhage of the ophthalmic artery or internal carotid artery and subsequent vision loss or death.
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Affiliation(s)
- Matthew J Zdilla
- Department of Natural Sciences and Mathematics, West Liberty University, West Liberty, West Virginia, USA
| | - Leah M Cyrus
- Department of Natural Sciences and Mathematics, West Liberty University, West Liberty, West Virginia, USA
| | - H Wayne Lambert
- Department of Neurobiology and Anatomy, West Virginia University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown, West Virginia, USA
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Miller TR, Jindal G, Krejza J, Gandhi D. Impact of Endovascular Technique on Fluoroscopy Usage: Stent-Assisted Coiling versus Flow Diversion for Paraclinoid Internal Carotid Artery Aneurysms. Neuroradiol J 2014; 27:725-31. [PMID: 25489897 DOI: 10.15274/nrj-2014-10094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 08/05/2014] [Indexed: 11/12/2022] Open
Abstract
Flow diversion is increasingly being utilized for the treatment of internal carotid artery (ICA) aneurysms. The purpose of this study was to evaluate the impact of endovascular technique--flow diversion versus stent-assisted coiling (SAC) on fluoroscopy time in patients treated for wide-neck paraclinoid ICA aneurysms. A retrospective review identified the 20 most recent consecutive patients treated for wide-neck paraclinoid ICA aneurysms by flow diversion and SAC respectively. Fluoroscopy time, cumulative dose area-product (DAP), contrast usage, intra-procedural complications, and total procedure time were collected and compared between the two treatment techniques. Treatment groups were comparable in terms of demographics, contrast usage, and clinical and angiographic outcomes. Flow diversion was associated with a significant reduction in fluoroscopy time (52.0 minutes versus 77.4 minutes), and demonstrated a strong trend towards shorter total procedure time (172 minutes versus 202 minutes). Average patient radiation exposure as measured by DAP was lower in the flow diversion group, 13225 mGy(x)cm(2) versus 15124 mGy(x)cm(2), although this finding was not statistically significant. There was no significant difference in contrast usage between the two groups, 152 ml and 159 (flow diversion and SAC respectively). The rate of complete aneurysm occlusion was higher in the flow diversion group (80% versus 60%). Endovascular treatment of paraclinoid ICA aneurysms with flow diversion is associated with shorter fluoroscopy times compared to stent-assisted coiling. There is also a likely reduction in overall procedure time. These results should be considered when recommending a treatment course for patients with such lesions.
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Affiliation(s)
- Timothy R Miller
- Department of Diagnostic Radiology, Neuroradiology, University of Maryland Medical Center; Baltimore MD, USA -
| | - Gaurav Jindal
- Department of Diagnostic Radiology, Neuroradiology, University of Maryland Medical Center; Baltimore MD, USA
| | - Jaroslaw Krejza
- Department of Diagnostic Radiology, Neuroradiology, University of Maryland Medical Center; Baltimore MD, USA
| | - Dheeraj Gandhi
- Department of Diagnostic Radiology, Neuroradiology, University of Maryland Medical Center; Baltimore MD, USA
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18
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Wang JT, Yang HC, Lin CF, Guo WY, Luo CB, Chen MH, Hsu SPC. Bilobulated paraclinoid aneurysm mimics double aneurysms: a comparison of endovascular coiling and surgical clipping treatments. J Chin Med Assoc 2014; 77:544-7. [PMID: 25238710 DOI: 10.1016/j.jcma.2010.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 09/21/2010] [Indexed: 11/21/2022] Open
Abstract
This report presents two cases of subarachnoid hemorrhage caused by rupture of paraclinoid aneurysms. Both aneurysms presented a bilobulated appearance upon image study. Both cases were treated successfully, the first with surgical clipping and the second with endovascular coiling. The special bilobulated feature of paraclinoid aneurysm in this particular anatomic location suggests its close relationship with the carotid dural ring. This relationship caused varying degrees of difficulty in both coiling and clipping the aneurysm. We compared the limitations and advantages of both treatments, and suggest that surgical clipping may be the treatment of choice in this region.
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Affiliation(s)
- Jui-To Wang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Chun-Fu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Min-Hsiung Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Sanford P C Hsu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC.
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19
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Lai LT, Morgan MK, Snidvongs K, Chin DCW, Sacks R, Harvey RJ. Endoscopic endonasal transplanum approach to the paraclinoid internal carotid artery. J Neurol Surg B Skull Base 2013; 74:386-92. [PMID: 24436941 DOI: 10.1055/s-0033-1347370] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 03/04/2013] [Indexed: 10/26/2022] Open
Abstract
Objective To investigate the relevance of an endoscopic transnasal approach to the surgical treatment of paraophthalmic aneurysms. Setting Binasal endoscopic transplanum surgery was performed. Participants Seven cadaver heads were studied. Main Outcome Measures (1) Dimensions of the endonasal corridor, including the operative field depth, lateral limits, and the transplanum craniotomy. (2) The degree of vascular exposure. (3) Surgical maneuverability and access for clip placements. Results The mean operative depth was 90 ± 4 mm. The lateral corridors were limited proximally by the alar rim openings (29 ± 4 mm) and distally by the distance between the opticocarotid recesses (19 ± 2 mm). The mean posteroanterior distance and width of the transplanum craniotomy were 19 ± 2 mm and 17 ± 3 mm, respectively. Vascular exposure was achieved in 100% of cases for the clinoidal internal carotid artery (ICA), ophthalmic artery, superior hypophyseal artery, and the proximal ophthalmic ICA. Surgical access and clip placement was achieved in 97.6% of cases for vessels located anterior to the pituitary stalk (odds ratio [OR] 73.8; 95% confidence interval [CI] 7.66 to 710.8; p = 0.00). Conclusion The endoscopic transnasal approach provides excellent visualization of the paraclinoid region vasculature and offers potential surgical alternative for paraclinoid aneurysms.
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Affiliation(s)
- Leon T Lai
- Department of Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Michael K Morgan
- Department of Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Kornkiat Snidvongs
- Department of Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - David C W Chin
- Department of Rhinology, Changi General Hospital, Singapore
| | - Ray Sacks
- Department of Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Richard J Harvey
- Department of Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Sydney, Australia ; Department of Neurosurgery, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
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