Tabani Halima, Yousef Sonia, Burkhardt Jan-Karl, Gandhi Sirin, Benet Arnau, Lawton Michael T
Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA.
Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA.
World Neurosurg. 2017 Aug;104:1045.e3. doi: 10.1016/j.wneu.2017.05.049. Epub 2017 May 18.
Most aneurysms originating from the clinoidal segment of the internal carotid artery (ICA) are nowadays managed conservatively, treated endovascularly with coiling (with or without stenting) or flow diverters. However, microsurgical clip occlusion remains an alternative. This video demonstrates clip occlusion of an unruptured right carotid cave aneurysm measuring 7 mm in a 39-year-old woman. The patient opted for surgery because of concerns about prolonged antiplatelet use associated with endovascular therapy. After patient consent, a standard pterional craniotomy was performed followed by extradural anterior clinoidectomy. After dural opening and sylvian fissure split, a clinoidal flap was opened to enter the extradural space around the clinoidal segment. The dural ring was dissected circumferentially, freeing the medial wall of the ICA down to the sellar region and mobilizing the ICA out of its canal of the clinoidal segment. With the aneurysm neck in view, the aneurysm was clipped with a 45° angled fenestrated clip over the ICA. Indocyanine green angiography confirmed no further filling of the aneurysm and patency of the ICA. Complete aneurysm occlusion was confirmed with postoperative angiography, and the patient had no neurologic deficits (Video 1). This case demonstrates the importance of anterior clinoidectomy and thorough distal dural ring dissection for effective clipping of carotid cave aneurysms. Control of venous bleeding from the cavernous sinus with fibrin glue injection simplifies the dissection, which should minimize manipulation of the optic nerve. Knowledge of this anatomy and proficiency with these techniques is important in an era of declining open aneurysm cases.
如今，大多数起源于颈内动脉（ICA）床突段的动脉瘤采用保守治疗、血管内栓塞治疗（带或不带支架）或血流导向装置治疗。然而，显微外科夹闭仍是一种选择。本视频展示了一名39岁女性未破裂的右侧颈动脉海绵窦段动脉瘤（直径7mm）的夹闭手术。由于担心血管内治疗需要长期使用抗血小板药物，患者选择了手术治疗。在获得患者同意后，进行了标准的翼点开颅术，随后进行硬膜外前床突切除术。打开硬脑膜并分开外侧裂后，打开床突瓣进入床突段周围的硬膜外间隙。沿圆周方向解剖硬脑膜环，将ICA的内侧壁游离至鞍区，将ICA从其床突段管中移出。在看清动脉瘤颈后，使用一个45°角的开窗夹在ICA上方夹闭动脉瘤。吲哚菁绿血管造影证实动脉瘤无进一步显影且ICA通畅。术后血管造影证实动脉瘤完全闭塞，患者无神经功能缺损（视频1）。该病例展示了前床突切除术和彻底的远端硬脑膜环解剖对于有效夹闭颈动脉海绵窦段动脉瘤的重要性。通过注射纤维蛋白胶控制海绵窦静脉出血简化了手术解剖过程，这应尽量减少对视神经的操作。在开放动脉瘤手术病例减少的时代，了解这种解剖结构并熟练掌握这些技术很重要。
