Microneurosurgery for Paraclinoid Aneurysms in the Context of Flow Diverters

Abstract

The advent of flow diverter (FD) stents has apparently reduced the role of microneurosurgery for paraclinoid aneurysms despite sparse high-quality evidence about their long-term effects.The present study critically reviews the overall results of a microneurosurgical series of 57 paraclinoid aneurysms.Of these aneurysms, 47.4% were regular in size while 19.3 were giant. Barami type I was predominant. In 21 aneurysms a hemorrhagic onset occurred. Pterional approach with intradural anterior clinoidectomy was preferred by far. Clipping was possible in 91.2% of aneurysms and a high-flow bypass was the choice in five cases. An mRS of 0–2 was achieved in 77.3% of patients, typically <50 years old.Visual field appeared improved or unchanged in 36.3% and 63.6% of the symptomatic patients, respectively. In 76.1% of incidental aneurysms, campimetry was unaffected by surgery.A complete aneurysm exclusion was achieved in 93% of cases using a single procedure. No recurrences were documented on an average follow-up of 54.1 ± 34 months.Microneurosurgery is still a valuable, definitive, and durable option for Barami type Ia, Ib, or II paraclinoid aneurysm, especially in patients <50 years old and visually symptomatic. Conditions other than these are ideal candidates for FD stents.

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

“…46 Direct surgery might be considered for Al-Rodhan group Ia, Ib, and II aneurysm when endovascular treatment has high risk of visual complications. 47…”

Microneurosurgical management of aneurysms of the A1 segment of the anterior cerebral artery: Anatomy and surgical technique

“…[ 6 , 7 , 14 , 21 , 31 ] The association with a paraclinoid ICA aneurysm, as in our second case, is not infrequent and has been already highlighted by our group elsewhere. [ 23 , 26 ] At around the 18–43 mm stage of human embryologic development, the distal ACA forms plexiform anastomoses with the primitive olfactory artery (POA), which, ultimately, divides into lateral (future MCA) and medial (future ACA) olfactory arteries. [ 33 ] These plexiform anastomoses between the ACA and POA ultimately coalesce into one AComA, but remnants from a failure of fusion of these anastomoses or an avascular remnant between the primitive precursors or a partial duplication of the A1 segment could result in A1 segment fenestrations that predispose to ACA aneurysms.…”

Surgical treatment of cerebrovascular diseases in a hybrid operating room

“…В настоящее время эффективными методами лечения в сосудистой нейрохирургии считают микрохирургию (МХ) и эндоваскулярную хирургию (ЭХ) [1,2]. В наиболее сложных случаях требуется одномоментное или последовательное использование данных методик, поскольку комплексный подход позволяет оптимизировать решение задач, которые невозможно или затруднительно выполнить одним из методов.…”