Methods from january 2009 to december 2011, 126 consecutive patients with 142 saccular paraclinoid aneurysms were treated with endovascular embolization at our institute. One patient was a 58yearold woman who had an unruptured paraclinoid ica aneurysm and a superior cerebellar artery sca aneurysm. Background current endovascular techniques have been widely used to treat paraclinoid aneurysms. Paraclinoid aneurysms include a subset with a relatively low rupture rate. Batjer and samson described the technique of suction decompression of the aneurysm by inserting a needle and aspirating blood from the internal carotid artery in the neck.
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. Microcatheter looping to facilitate aneurysm selection in. Vision outcomes in patients with paraclinoid aneurysms. We do not believe that the medial or lateral sides of the ica are origin sites of such aneurysms. Request pdf endovascular treatment of paraclinoid aneurysms paraclinoid aneurysms include those that are distal to the cavernous segment of the internal carotid artery and proximal to the. Pdf clinical outcome of paraclinoid internal carotid. Read endovascular treatment of a ruptured paraclinoid aneurysm of the carotid syphon achieved using endovascular stent and endosaccular coil placement, american journal of neuroradiology on deepdyve, the largest online rental service for scholarly research with thousands of academic publications available at your fingertips. Among 61 patients, two patients died after either surgical clipping or endovascular coiling. Even when the treatment of paraclinoid aneurysms seems to be more difficult than any other aneurysm of the anterior circulation, from the surgical point of view, however, clipping of these aneurysms requires essentially the same surgical technique. The purpose of this study was to determine whether contrastenhanced ce 3d constructive interference in steady state ciss mr imaging is useful to differentiate between paraclinoid and cavernous sinus aneurysms. Background stent assistance for treatment of widebased aneurysms is becoming rapidly accepted. Surgical treatment of paraclinoid aneurysms neupsy key.
The 3d ct angiography showed the paraclinoid internal carotid artery aneurysm directed to superolateral side fig. Paraclinoid carotid aneurysms pose the risk for subarachnoid hemorrhage sah and may be considered for treatment. Information collected included patient demographics, risk factors including a history of ischemic cerebrovascular disease, smoking, hypertension, and a family history of intracranial aneurysms, and length of hospital stay. It should be emphasized that during the growth process of a paraclinoid aneurysm, the dome could occupy anatomic spaces at the medial or lateral side of the ica. Nonaka t1, haraguchi k, baba t, koyanagi i, houkin k. Object this study was undertaken to analyze the features that define subclinoid aneurysms. Angiographic characteristics of ruptured paraclinoid. Surgical clipping is still a good choice for the treatment.
This is the pathophysiologic side of argument against a separate lacerum segment. Modified extradural temporopolar approach with suction. Microsurgery of paraclinoid aneurysm youmans chapter 366 rose du, arthur l. A surgical case of paraclinoid carotid aneurysm associated. Studies that reported on aneurysms arising between the cavernous sinus and the origin. The 2d angiography showed that the aneurysm was situated in the site of the hemorrhage. The entire shaft of the power drill is exposed in the operative field. Patients with paraclinoid aneurysms commonly present with visual impairment. Fulltext articles were included if they reported both preoperative and postoperative vision data for at least 5 patients with paraclinoid aneurysms treated with clipping, coiling, or fd. Clinical outcome of paraclinoid internal carotid artery. Fenestration of the supraclinoid internal carotid artery connecting the neck of the paraclinoid aneurysm and the origin of the posterior communicating artery. Paraclinoid aneurysm with dome superiorly directed. The pterional approach and extradural anterior clinoidectomy to clip paraclinoid aneurysms jung soo kim, sunil lee, kyoung dong jeon, byeong sam choi department of neurosurgery, haeundae paik hospital, inje university colleage of medicine, busan, korea objective. Details of the inclusion and exclusion process are outlined in fig.
The complex anatomy of the paraclinoid internal carotid artery ica makes the surgical management of aneurysms arising from this segment difficult. Bu videonun konusu paraclinoid ica aneurysm murat ulutas. Paraclinoid aneurysms originate from the internal carotid artery between the distal dural ring and the posterior communicating artery. Angiographic characteristics of ruptured paraclinoid aneurysms. Paraclinoid aneurysms should be assessed jointly by the neurosurgeon and the endovascular team to choose the proper management strategy. Paraclinoid aneurysms, such as carotidophthalmic aneurysms, represent 5% of all intracranial aneurysms. Supraclinoid aneurysm definition at, a free online dictionary with pronunciation, synonyms and translation.
Considering the low incidence of rupture, investigation of the characteristics of ruptured paraclinoid aneurysm is important to predict rupture risk of the paraclinoid aneurysms. Surgical treatment of large and giant paraclinoid ica aneurysms are technically challenging for many neurosurgeons. We identified 70 aneurysms treated with stent assistance including. Anterior clinoidectomy for paraclinoid aneurysms in.
Patients with paraclinoid aneurysms with other distal aneurysms not well suited for endovascular treatment or with hematoma from ruptured paraclinoid aneurysms needing evacuation may best be managed with microsurgery. The suprasellar variant is a true superior hypophyseal aneurysm and extends medially or superomedially into the suprasellar space. Schematic illustration ii of microcatheter looping for aneurysm selection. There were 20 ruptured and 22 unruptured aneurysms. We describe consecutive patients and the clipping of complicated, largesized paraclinoid aneurysms using a modified extradural. One patient had a giant intracavernous aneurysm, a large paraclinoid aneurysm, and two middle cerebral artery bifurcation aneurysms on the same side. Differentiation between paraclinoid and cavernous sinus aneurysms of the internal carotid artery ica is critical when considering treatment options.
Request pdf neck clipping of paraclinoid small aneurysms paraclinoid small aneurysms with a diameter less than 5 mm may be difficult to handle intraoperatively. Retinal artery occlusion following coil embolization of. Endovascular treatment of unruptured paraclinoid aneurysms. Definition aneurysms arising from the internal carotid artery ica in close proximity to the anterior clinoid process beyond the venous lumen of the cavernous sinus and proximal to the origin of the. A highspeed powerdrilling technique of anterior clinoidectomy has been advocated in all publications on paraclinoid region surgery. In this video abstract, we present an intradural anterior clinoidectomy for management of some paraclinoid aneurysms. In order to treat paraclinoid aneurysms, it is necessary to use a combination of these intraoperative monitoring techniques, in addition to gaining information on the anatomy, size, collateral flow pattern, and patient age. Microcatheter tip directed to dome of aneurysm as looped microcatheter advanced to distal ica. These include 1p3436, 2p1415, 7q11, 11q25, and 19q. Review of cerebral aneurysm formation, growth, and rupture. Internal carotid artery aneurysm aneurysm of int carotid. The surgical clipping of paraclinoid segment internal carotid. However, this method carries a risk of arterial dissection and distal embolization. Paraclinoid aneurysms are an uncommon cause of aneurysmal sah, and their treatment is challenging.
Microsurgical treatment of carotidophthalmic aneurysm associated. From january 2016 to december 2017, we enrolled a total of 1 paraclinoidal aneurysms treated with embolization. Aneurysms arising from the ica between the roof of the cavernous sinus and the origin of the posterior communicating artery pcoma are. The risk of rupturing the aneurysm during surgery is greatly diminished by not placing a device inside the aneurysm. Paraclinoid internal carotid artery aneurysms originate from the internal carotid artery between the distal dural ring and the posterior communicating artery. Shaping and navigating methods of microcatheters for. The segment is known as the carotidophthalmic segment and the paraclinoid segment. 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. A brain aneurysm is a bulge that forms in the blood vessel of your brain that could lead to severe health issues and possibly death. Before embracing flow diversion in larger numbers of patients with paraclinoid aneurysms, it is important to know the safety and efficacy of traditional endovascular methods for these aneurysms. The key features of successful surgical treatment of these lesions include establishing control of the proximal artery, adequate exposure of the aneurysm neck.
Aneurysms develop because of a weakness in the wall of the vessel, usually at branch points. Internal carotid artery icaophthalmic artery aneurysms constitute. Unruptured paraclinoid aneurysm has a low risk of rupture compared to other types of cerebral aneurysm. Artery junction points may become weak, causing ballooning of the blood vessel wall that can form a small sac or aneurysm. In the past, treatment involved surgical clipping of the aneurysm, which is associated with 4% morbidity and 1% mortality even in elective cases. The anatomical complexity of the paraclinoid region has made surgical treatment of intracranial ophthalmic segment aneurysms osas difficult. Paraclinoid aneurysms are located in the clinoid and ophthalmic segments of the ica. Computed tomography scan done at another facility showed a round mass lesion near the sella.
Paraclinoid aneurysms are defined as aneurysms arising from the internal carotid artery ica in close proximity to the anterior clinoid process. This report presents a 60yearold with a large paraclinoid carotid aneurysm associated with cervical interal carotid artery ica dissection cicad. The surgical indications for unruptured paraclinoid aneurysm should consider this low rupture risk as well as several other factors such as the aneurysm shape, the aneurysm size, and how old the patient. Giant, multiple and bilateral aneurysms are more frequent in. The paraclinoid space is delineated by the ventral ica surface just distal to the distal ring superiorly, the roof of the cavernous sinus. Vision outcomes in patients with paraclinoid aneurysms treated with. Surgical treatment of paraclinoid aneurysms clinical gate. Her gcs score was 15, and the paraclinoid ica aneurysm measured mm in its greatest dimension. This type of aneurysm should not be diagnosed only because of size and shape. We describe a revised technique for suction decompression of paraclinoid aneurysms. Characterization of paraclinoid aneurysms may be difficult because of. These cases were selected because the aneurysms had the same features as the only previously described. Methods cases of aneurysms arising in the paraclinoid location of the internal carotid artery treated with intracranial stents andor bare platinum coils were analyzed retrospectively from our prospectively collected database. The diagnosis and treatment of unruptured paraclinoid aneurysms has been increasing with the recent advent of diagnostic tools and less invasive endovascular therapeutic options.
The indication for treatment of unruptured intracranial aneurysms is controversial. Aneurysm recurrence after treatment of paraclinoid. To investigate the hemodynamic features before and after embolization of paraclinoidal aneurysms using hemodynamic numerical simulation and the influence of embolization on recurrence after embolization. Ophthalmic aneurysms were most common 29%, followed by superior hypophyseal 17%, carotid cave 17%, anterior carotid wall 17% aneurysms, posterior wall. Differentiation between paraclinoid and cavernous sinus. Methods five cases of laterally directed carotid artery ca aneurysms adjacent to the anterior clinoid process acp were identified in a series of approximately 1400 surgically treated aneurysms. Surgery is the firstline therapy for paraclinoid aneurysms type i, unless the neck of the aneurysm is heavily. A case report ga y lee, gi w shin, hyun s jung, jin w baek, young j heo, yoo j lee, hye j choo, and hae w jeong. In order to determine the risk factors related to aneurysm rupture, we studied the aneurysms at the paraclinoid segment of the internal carotid artery by applying morphologic and hemodynamic. In clinical practice, this means that a 3mm aneurysm arising from the anterior communication artery has a higher risk of rupture than a 3mm aneurysm of the paraclinoid internal carotid artery.
Intrasellar rupture of a paraclinoid aneurysm with subarachnoid. Endovascular treatment of ruptured paraclinoid aneurysms. Roadmap image to navigate a steamshaped ssimple microcatheter over a microguidewire b shows that the tip of the microcatheter is looped and ushaped by the advancing force on the curved tip against the artery wall in the ophthalmic segment. For unruptured carotid cave and small paraclinoid aneurysms, decisionmaking regarding whether or not to treat the aneurysm may be the most difficult step 23. She had a fall while riding a bicycle and hit her head on the ground. Neck clipping of paraclinoid small aneurysms request pdf. But most brain aneurysms dont cause any symptoms, and only a. Flow diversion is one method of removing the need to enter the aneurysm, which is the most dangerous part of endovascular treatment of aneurysms. Angiographically, more conservative indication for the treatment of paraclinoid aneurysm should be recommended except for superior located lesions.
Paraclinoid aneurysm is defined as an aneurysm that originates at the internal carotid artery ica distal to the. The acp was an obstacle to clipping the aneurysm fig. A new endovascular strategy, flow diversion, is gaining importance in the treatment of these aneurysms. Pdf the pterional approach and extradural anterior. Retrograde suction decompression of paraclinoid aneurysma. Flow diversion with stents for aneurysms treatment. Microsurgical treatment of carotidophthalmic aneurysm assoc. A flow diversion procedure may be performed to treat an unruptured brain aneurysm. Endovascular treatment of paraclinoid aneurysms ncbi. Endovascular treatment of paraclinoid aneurysms request pdf. Fenestration of the supraclinoid internal carotid artery. Coiling demonstrated a higher rate of rebleeding, but a lower mortality rate and a higher rate of disabilityfree survival at 10 years.
Chapter 72 surgical treatment of paraclinoid aneurysms edgar nathal, gabriel castillo the portion of the proximal intradural internal carotid artery ica adjacent to the anterior clinoid process acp is called the paraclinoid segment. Microsurgery of paraclinoid aneurysms clinical gate. Hoh et al 80 analyzed 30 patients with multiple cas where each patient harbored 1 ruptured lesion and. T1 aneurysm recurrence after treatment of paraclinoidophthalmic segment aneurysms a treatmentmodality assessment. Endovascular treatment of a ruptured paraclinoid aneurysm. Obliteration of the largegiant paraclinoid aneurysms with endovascular treatment has a lower success rate for total occlusion. To assess the effectiveness and safety of endovascular treatment of ruptured paraclinoid aneurysms, we performed a retrospective analysis of 33 patients. A small superiorly directed paraclinoid aneurysm is shown on internal carotid artery angiogram a. Using the broadest definition, such aneurysms could include those arising from the intracavernous, clinoidal, ophthalmic, and posterior communicating ica segments. Because of the complex anatomical association among vascular, dural, and bony structures, paraclinoid internal carotid artery ica aneurysms remain a major challenge for vascular neurosurgeons. Hemodynamic characteristics associated with paraclinoid.
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