Multimodality Treatment of Complex Unruptured Cavernous and Paraclinoid Aneurysms

Kim, Louis J.; Tariq, Farzana; Levitt, Michael R.; Barber, Jason; Ghodke, Basavaraj; Hallam, Danial K.; Sekhar, Laligam N.

doi:10.1227/neu.0000000000000192

Cited by 41 publications

(25 citation statements)

References 42 publications

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“…Previous studies focused on the treatment of large and giant wide-necked aneurysms between the petrous and cavernous segments of the ICA, for which the PED was approved originally. 4,6,24,37,40,46 These promising results led to increasing off-label use of the PED for aneurysms that are not large and not wide necked, and several groups have found similarly strong results after treating small aneurysms 11,17,26 and other off-label applications. 2,10,13,28,32,36 Still, the number of studies on use of the PED to treat small aneurysms has been limited, and very few have directly compared patient outcomes with those of patients after coiling or clipping.…”

Section: Discussionmentioning

confidence: 99%

“…Our results corroborate the findings of these studies and also provide data from a direct comparison of PED placement to coiling and clipping among patients treated over a 6-year period. In 1 of the few other comparative studies, Kim et al 26 reported the treatment of 24 paraclinoid aneurysms with PED placement, 24 with clipping, and 41 with stent-assisted coiling. Treatment with a PED resulted in complete aneurysm occlusion in 81% of the patients, and they found a 13% rate of posttreatment cranial nerve palsy, compared to a 0% rate after coiling and a 29% rate after clipping.…”

Section: Discussionmentioning

confidence: 99%

“…Few studies have reported specifically on vision outcomes, and very few studies have compared PED placement directly to clipping and coiling. 26,30 Given the increasing use of PEDs to treat paraclinoid aneurysms, we performed a retrospective analysis of 115 patients (with a total of 125 paraclinoid aneurysms) treated with PED placement, clipping, or coiling. This 2-site study is one of the largest to have directly compared flow diversion to clipping and coiling in a population of patients with such an aneurysm.…”

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Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Silva

See

Khandelwal

et al. 2019

Journal of Neurosurgery

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OBJECTIVE Paraclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%-40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling. METHODS The authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention. RESULTS A total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03). CONCLUSIONS In a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Silva

See

Khandelwal

et al. 2019

Journal of Neurosurgery

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“…Paraclinoid aneurysms are increasingly being treated with flow-diversion stents, which may further reduce the procedural risks associated with endovascular treatment. [22][23][24][25] Angiographic and clinical outcomes from previous studies are summarized in Table 7. The immediate complete occlusion rate in our series was low (9.5%) compared with those in earlier studies (28.2%-86.6%).…”

Section: Discussionmentioning

confidence: 99%

Endovascular Treatment of Unruptured Paraclinoid Aneurysms: Single-Center Experience with 400 Cases and Literature Review

Shimizu

Imamura

Mineharu

et al. 2015

AJNR Am J Neuroradiol

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“…7,8,10,17,18,25 It is important to differentiate the exact location of the paraclinoid aneurysm, whether intradural or not, when considering treatment options. The distal dural ring (DDR) is the anatomical boundary between the intra-and extradural segments of the internal carotid artery (ICA) in the paraclinoid region.…”

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Comparison of the effectiveness of using the optic strut and tuberculum sellae as radiological landmarks in diagnosing paraclinoid aneurysms with CT angiography

Liao

Lin²,

Lin

et al. 2016

JNS

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T he treatment of paraclinoid aneurysms remains challenging. 7,8,10,17,18,25 It is important to differentiate the exact location of the paraclinoid aneurysm, whether intradural or not, when considering treatment options. The distal dural ring (DDR) is the anatomical boundary between the intra-and extradural segments of the internal carotid artery (ICA) in the paraclinoid region. 2,9,19,24 Some studies tried to delineate the DDR with imaging methods and differentiate the aneurysm in the vicinity of the anterior clinoid process (ACP). 5,16,23 However, these studies either lacked direct surgical confirmation or comprised a small case number.aBBreViatiONS ACP = anterior clinoid process; C 4 = cavernous segment; C 5 = clinoid segment; C 6 = ophthalmic segment; CTA = CT angiography; DDR = distal dural ring; DSA = digital subtraction angiography; ICA = internal carotid artery; OphA = ophthalmic artery; OS = optic strut; PDR = proximal dural ring; ROC = receiver operating characteristic; TS = tuberculum sellae. OBJectiVe The treatment of paraclinoid aneurysms remains challenging. It is important to determine the exact location of the paraclinoid aneurysm when considering treatment options. The authors herein evaluated the effectiveness of using the optic strut (OS) and tuberculum sellae (TS) as radiographic landmarks for distinguishing between intradural and extradural paraclinoid aneurysms on source images from CT angiography (CTA). methOdS Between January 2010 and September 2013, a total of 49 surgical patients with the preoperative diagnoses of paraclinoid aneurysm and 1 symptomatic cavernous-clinoid aneurysm were retrospectively identified. With the source images from CTA, the OS and the TS were used as landmarks to predict the location of the paraclinoid aneurysm and its relation to the distal dural ring (DDR). The operative findings were examined to confirm the definitive location of the paraclinoid aneurysm. Statistical analysis was performed to determine the diagnostic effectiveness of the landmarks. reSultS Nineteen patients without preoperative CTA were excluded. The remaining 30 patients comprised the current study. The intraoperative findings confirmed 12 intradural, 12 transitional, and 6 extradural paraclinoid aneurysms, the diagnoses of which were significantly related to the type of aneurysm (p < 0.05) but not factors like sex, age, laterality of aneurysm, or relation of the aneurysm to the ophthalmic artery on digital subtraction angiography. To measure agreement with the correct diagnosis, the OS as a reference point was far superior to the TS (Cohen's kappa coefficients 0.462 and 0.138 for the OS and the TS, respectively). For paraclinoid aneurysms of the medial or posterior type, using the base of the OS as a reference point tended to overestimate intradural paraclinoid aneurysms. The receiver operating characteristic curve indicated that if the aneurysmal neck traverses the axial plane 2 mm above the base of the OS, the aneurysm is most likely to grow across the DDR and present as a transitional ane...

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Multimodality Treatment of Complex Unruptured Cavernous and Paraclinoid Aneurysms

Cited by 41 publications

References 42 publications

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Endovascular Treatment of Unruptured Paraclinoid Aneurysms: Single-Center Experience with 400 Cases and Literature Review

Comparison of the effectiveness of using the optic strut and tuberculum sellae as radiological landmarks in diagnosing paraclinoid aneurysms with CT angiography

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