Bilateral ophthalmic segment aneurysm clipping with one craniotomy:operative technique and results

Abstract

AIm: Surgical indications for ophthalmic segment aneurysms are getting narrower due in part to success of endovascular techniques like flow diverters. Wide necks, large size, intraluminal thrombus, optic nerve compression or recurrence after endovascular therapy make the case for surgical treatment. Bilateral aneurysms are less established but worth considering surgical indication. Our objective is to review a series of bilateral ophthalmic segment aneurysms managed through a single craniotomy, describe the surgical technique and evaluate the results. mATERIAl and mEThods: Between 1997 and 2012, 11 patients with bilateral ophthalmic segment aneurysms were treated through a single craniotomy at UCSF Medical Center. An intradural clinoidectomy was performed to expose and clip the ipsilateral aneurysm. Medially and superiorly projecting contralateral aneurysm could be clipped through the interoptic triangle without clinoidectomy. Indocyanin green videoangiography was performed routinely.REsulTs: Eleven patients harboring 22 ophthalmic segment aneurysms were treated with a single craniotomy. Complete neck occlusion was achieved in 96 % of aneurysms. One patient presenting with subarachnoid hemorrhage Hunt-Hess grade 5 died from vasospasm complications. The remaining 10 patients had good outcomes (mRS ≤ 2) after a mean 2.2 years follow up. There were no recurrences after surgical treatment. CoNClusIoN:Decompressing the optic nerve, completely occluding the aneurysm neck, providing a durable repair and avoiding antiplatelet agents are the well established advantages of microsurgical management. This experience demonstrates safety and feasibility of contralateral clipping of carefully selected ophthalmic segment aneurysms, thus pointing another advantage of surgical clipping when bilateral aneurysms are diagnosed. KEywoRds: Bilateral aneurysm, Ophthalmic segment, Surgical clipping, Treatment ÖZAmAÇ: Oftalmik kısım anevrizmalarında cerrahi tedavi endikasyonları akım yönlendiriciler gibi endovasküler tekniklerin gelişmesiyle giderek daralmaktadır. Geniş boyunlu, büyük boyutlu, lumen içi thrombuslu, optik sinir basılı veya endovasküler cerrahi sonrası nüks olan olgularda cerrahi ön plana çıkmaktadır. Bilateral anevrizma varlığı ise daha az değerlendirilen ama cerrahi düşünülmesine değer bir durumdur. Amacımız, tek bir kraniotomi ile tedavi edilen bilateral oftalmik kısım anevrizmalı hasta serisini incelemek, cerrahi tekniği tanımlamak ve sonuçları değerlendirmektir. yÖNTEm ve GEREÇlER: 1997-2012 yılları arasında UCSF Tıp Merkezi'nde 11 bilateral oftalmik kısım anevrizmalı hasta tek kraniotomi ile tedavi edilmiştir. İpsilateral anevrizmayı ortaya koymak ve kliplemek için intradural klinoidektomi yapılmıştır.Mediale ve superior uzanan kontrlateral anevrizmalar klinoidektomi yapılmaksızın interoptik üçgenden kliplenmiştir. Indocyanin yeşili videoanjiyografi rutin olarak kullanılmıştır.BulGulAR: 22 oftalmik kısım anevrizması olan 11 hasta tek kraniotomi ile tedavi edildi. Hastaların % 96'sında anevrizma boynu tam kapa...

Clipping of Bilateral Ophthalmic Artery Aneurysms Through a Single Craniotomy

“…Anterior clinoidectomy appears to be the greatest risk to vision, due to drilling the clinoid process, injury to small perforators on the optic nerve, direct manipulation during the dissection of the distal dural rings, or a combination of these factors [9].…”

Simultaneous Craniotomies for Multiple Intracranial Aneurysm Clippings—One-Stage Surgery with Multiple Craniotomies

“…Even in cases of lesions in multiple areas, single craniotomies may be attempted [1,22]. In other cases, multimodality treatment [2] or staged operations are attempted [24,27]. Staged operations may be performed in cases where the lesion is at a location that requires different craniotomies, such as in bilateral middle cerebral artery aneurysms.…”

Simultaneous Craniotomies for Multiple Intracranial Aneurysm Clippings – One-stage Surgery with Multiple Craniotomies

“…Even in cases of lesions in multiple areas, single craniotomies may be attempted [1,22]. In other cases, multimodality treatment [2] or staged operations are attempted [24,27]. Staged operations may be performed in cases where the lesion is at a location that requires different craniotomies, such as in bilateral middle cerebral artery aneurysms.…”