Optic Foraminotomy versus Anterior Clinoidectomy for Small Superior-Projecting Paraclinoid Aneurysms: Visual and Angiographic Outcome Evaluation.

INTRODUCTION: Optic foraminotomy (OF) has been recently proposed as an alternative to anterior clinoidectomy (AC) for selected types of paraclinoid aneurysms. In this study, OF and AC were compared for small superior-projecting paraclinoid aneurysms assuming visual and angiographic results as outcome measures. Indications for OF are also discussed. METHODS: Data of patients who underwent surgery for a paraclinoid aneurysm in the last 10 years were collected across 3 tertiary hospitals. Small to regular-size and superior projecting aneurysms were sorted. Multiple and complex aneurysms were excluded. Records of patients who went through OF were compared with those of patients who underwent AC. Neurologic outcome was reported as a modified Rankin Scale. Aneurysm complete occlusion rate and rate of approach-related worsened vision were selected as outcome measures of efficacy and safety, respectively, of the OF versus AC. Unpaired t test and χ2 test were used for numerical and categorical variables, respectively. A P value less than 0.05 was considered statistically significant. RESULTS: OF and AC groups involved 18 and 25 patients, respectively. Complication rate, overall neurologic outcome, rate of approach-related worsened vision, and complete occlusion rate did not differ between the groups. The average follow-up was 51 ± 34 and 60 ± 41 months in the OF and AC groups, respectively. CONCLUSIONS: Compared to AC, OF did not show either a higher rate of approach-related worsened vision or a lower aneurysm complete occlusion rate. OF can be considered a valid alternative to the AC for small superior-projecting dorsal ICA wall paraclinoid aneurysms.

Optic Foraminotomy for Clipping of Superior Carotid-Ophthalmic Aneurysms.

Background: Carotid-ophthalmic aneurysms usually cause visual problems. Its surgical treatment is challenging because of its anatomically close relations to the optic nerve, carotid artery, ophthalmic artery, anterior clinoid process, and cavernous sinus, which hinder direct access. Despite recent technical advancements enabling risk reduction of this complication, postoperative deterioration of visual function remains a significant problem. Therefore, the goal of preserving and/or improving the visual outcome persists as a paramount concern. Objective: We propose optic foraminotomy as an alternative microsurgical technique for dorsal carotid-ophthalmic aneurysms clipping. As a secondary objective, the step by step of that technique and its benefits are compared to the current approach of anterior clinoidectomy. Methods: We present as an example two patients with superior carotid-ophthalmic aneurysms in which the standard pterional craniotomy, transsylvian approach, and optic foraminotomy were performed. Surgical techniques are presented and discussed in detail with the use of skull base dissections, microsurgical images, and original drawings. Results: Extensive opening of the optic canal and optic nerve sheath was successfully achieved in all patients allowing a working angle with the carotid artery for correct visualization of the aneurysm and further clipping. Significant visual acuity improvement occurred in both patients because of decompression of the optic nerve. Conclusion: Optic foraminotomy is an easy and recommended technique for exposing and treating superior carotid-ophthalmic aneurysms and allowing optic nerve decompression during the first stages of the procedure. It shows several advantages over the current anterior clinoidectomy technique regarding surgical exposure and facilitating visual improvement.

Microsurgical Clipping of Carotid-Ophthalmic Tandem Aneurysms: Case Report and Surgical Nuances.

Tandem intracranial aneurysms (TandIAs) are rare but inherently complex, and special technical considerations are required for their surgical management. The present case highlights the key surgical aspects of two carotid-ophthalmic TandIAs incidentally found in a 60-year-old female. Both the aneurysms were superiorly projecting, regular in size, and involved the left ophthalmic segment of the internal carotid artery (ICA). The minimum distance between the necks was 3 mm. The patient underwent microsurgery because of the reported major complications rate of the endovascular treatment in the case of a very short minimum distance between the TandIAs. After cervical ICA exposure, both the aneurysms were excluded through a pterional approach. Intradural anterior clinoidectomy and unroofing of the optic canal allowed the mobilization of the left optic nerve. The more distal aneurysm was clipped before the opening of the distal dural ring of the ICA. The proximal aneurysm was clipped with two straight clips stacked perpendicular to the ICA. A small remnant was intentionally left to avoid the stenosis of the ophthalmic artery. Postoperative angiography showed the exclusion of both the aneurysms with a small dog-ear of the more proximal one. The patient was discharged neurologically intact and, after one year, the remnant remained stable. Microsurgical clipping is a definitive and durable treatment for carotid-ophthalmic TandIAs. In the case of a very short minimum distance between the aneurysms, the distal one should be clipped first to make the anterior clinoidectomy, opening of the distal dural ring of the ICA, and clipping of the more proximal aneurysm easier.

Intradural "limited drill" technique of anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment and PCOM aneurysms-review of surgical results.

To evaluate the safety and efficacy of intradural "limited drill" technique (ILDT) of anterior clinoidectomy (AC) and optic canal unroofing (OCU) for microneurosurgical management of ophthalmic segment and posterior communicating artery (PCOM) aneurysms. All the patients with ophthalmic segment and PCOM aneurysms who underwent AC and OCU by ILDT for microneurosurgical management of ophthalmic segment and PCOM aneurysms during 4-year period (2013-2016) at our Institute were included in this study. In ILDT of AC and OCU, the use of power drill is restricted to AC only and OCU is done exclusively with 1-mm Kerrison punch. AC and OCU by ILDT were done in 24 patients with 29 ophthalmic segment and 7 PCOM aneurysms. AC and OCU by ILDT helped in mobilization of optic nerve/internal carotid artery (ICA) and provided excellent exposure for all these aneurysms. There was no injury to ICA or optic nerve during drilling. AC and OCU facilitated clip ligation of 34 of these aneurysms. Remaining 2 aneurysms were considered not suitable for clipping. Check angiogram done for 33 aneurysms revealed complete obliteration of 26 aneurysms, very small residual neck in 5 aneurysms, and small residual aneurysm in 2 aneurysms. Deterioration in vision was noted in 1 patient (4.1%). In 6 patients with preoperative visual deficits, significant improvement in vision was noted in 4 patients (4/6-66.6%) after surgery. Good outcome (MRS < 2) was noted in 91.6% (22/24) of these patients. ILDT is a safe and effective technique of AC and OCU which provide good exposure for ophthalmic segment and PCOM aneurysms.

Predictors for ophthalmic segment aneurysms recanalization after coiling and flow diverter embolization in 6- and 12-month follow-up.

Carotid-ophthalmic aneurysms are indication for endovascular treatment. Coil embolization is associated with a high recanalization rate and thus usage of flow diverter (FD) could constitute the treatment of choice. Although implementation of FD is very effective, it carries a significant risk of complications. The goal of our study was to find a radiological recanalization marker in order to facilitate decision process which would result in fewer treatment-related complications and in this way, to personalize endovascular therapy. We made a retrospective analysis of seventy-five patients with saccular carotid-ophthalmic aneurysms treated endovascularly. Morphometric measurements were performed in CTA 3D aneurysm models. The aneurysm size and volume were measured on the base of digital subtraction angiography (DSA) images. The treatment effectiveness was determined visually using the modified Raymond Roy classification after embolization and on the 6- and 12-month follow-up DSA. Statistica 13.1 software was used. Multivariate analyses showed that the aneurysm neck size (OR 2.51; 95%CI: 1.20-5.26), aspect ratio (OR 2.60; 95%CI: 1.27-5.21) and neck to parent artery ratio (OR 2.68; 95%CI: 1.26-5.70) were risk factors for carotid-ophthalmic aneurysms recanalization after 6 months. Of those factors, aneurysm neck size remained the only significant risk factor for carotid-ophthalmic aneurysms recanalization after 12 months (OR 5.23, 95%CI: 1.71-15.93). Various factors seem to influence recanalization. Preoperatively, if the above-mentioned predictors of recanalization are present, coiling is burdened with a high recanalization rate. In those cases, FD embolization should be considered.

Carotid-ophthalmic aneurysms-Our results and treatment strategy.

OBJECTIVE: Ophthalmic aneurysms comprise 1.3-5% of all intracranial aneurysms and are the least likely to rupture. On the other hand, they can cause symptoms (visual dysfunction and eye movement palsy) in 18-35% of cases even when unruptured. In our article, we review all the cases of ophthalmic aneurysms treated in our department, discuss treatment methods, and compare our results with those reported in the literature. MATERIAL AND METHODS: In the period 1998-2010, we operated on 37 patients and treated 21 endovascularly. Out of these surgically/endovascularly treated, there were 11/7 asymptomatic, 3/2 unruptured symptomatic, and 23/12 ruptured casess. RESULTS: Surgically treated: Asymptomatic aneurysms were operated on with 9% (1 patient) mortality (due to delayed infection); 87% of patients with ruptured aneurysms improved, 9% remained unchanged, and 4% got worse. Visual dysfunction was restored in 66% of unruptured symptomatic cases (2 patients operated on within 1 month of the start of symptoms). Endovascularly treated. Asymptomatic aneurysms were coiled with 9% (1 patient) mortality and 9% (1 patient) morbidity. Patients with ruptured aneurysms improved in 50% of cases, 25% of patients did not change, 1 patient got worse (12.5%), and 1 patient died (12.5%). Only 1 of 3 coiled patients showed improved 3rd nerve palsy after coiling of an unruptured aneurysm. CONCLUSION: The mortality and morbidity of aneurysms treated in our department, both unruptured and ruptured, were relatively low and comparable with the results presented in the literature. The number of unruptured aneurysms with visual dysfunction was not as high as reported in the literature, but our results correlate with the main conclusion of those studies: to treat those aneurysms surgically when possible and within three months from the start of symptoms.

Outcomes for unruptured ophthalmic segment aneurysm surgery.

Ophthalmic segment aneurysms present unique technical challenges because of their proximity to the optic nerve and the anterior clinoid process. The current study was performed to examine whether surgery for unruptured ophthalmic segment aneurysms is an effective treatment modality with acceptable complication rates. A consecutive case series (prospectively collected data) was retrospective reviewed for the period between April 1992 and August 2012. Clinical results, operative complications, angiographic outcomes and prognostic factors associated with surgery are presented. Of the 169 patients with 182 unruptured ophthalmic segment aneurysms that were surgically repaired, 11 (6.4%) experienced new permanent neurological deficits, including six instances of complete visual loss. There was one postoperative death (0.6%) related to a middle cerebral artery infarction. Transient morbidity occurred in 18 patients (10.4%), including cerebrospinal fluid rhinorhea (10 patients), oculomotor nerve palsy (four patients) and transient dysphasia (four patients). A total of 142 aneurysms (78.0%) had documented postoperative angiography. Surgical treatment resulted in 135 (95.1%) complete obliterations and seven (4.9%) neck remnants. Retreatment was performed in three patients (1.7%). Logistic regression analysis of risk factors revealed that age (p < 0.02), aneurysm size (p < 0.01) and the use of temporary clipping (p < 0.01) were significant negative predictors of outcome. The risk associated with surgical repairs for unruptured ophthalmic segment aneurysms is no greater than aneurysms in other locations (6.4% morbidity; 0.6% mortality) and no more hazardous than outcomes achieved by alternative therapies. The robustness of aneurysm repair achieved by open microsurgery is an important consideration.