1Department of Neurological Surgery, University of California, San Francisco, California; and.
2Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital & Medical Center, Phoenix, Arizona.
J Neurosurg. 2018 Dec 1;129(6):1511-1521. doi: 10.3171/2017.7.JNS17673. Epub 2018 Jan 26.
OBJECTIVEWhile most paraclinoid aneurysms can be clipped with excellent results, new postoperative visual deficits are a concern. New technology, including flow diverters, has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can. The increasing endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. The authors, therefore, undertook this study to define patient, visual, and aneurysm outcomes in the most common type of paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms.METHODSResults from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc.), clinical characteristics, and patient outcomes were recorded and analyzed.RESULTSDespite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of 208 cases, with OphA patency preserved in 99.5%. The aneurysm recurrence rate was 3.1% and the retreatment rate was 0%. Good outcomes (modified Rankin Scale score 0-2) were observed in 96.2% of patients overall and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 8 patients (3.8%), decreased visual acuity in 5 (2.4%), and monocular blindness in 9 (4.3%). Vision improved in 9 (52.9%) of the 17 patients with preoperative visual deficits.CONCLUSIONSThe most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes, and aggressive medical management postoperatively might potentially decrease the incidence of delayed visual deficits. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.
目的
虽然大多数鞍旁动脉瘤可以通过夹闭获得良好的效果，但新的术后视力缺损仍是一个关注点。新技术，包括血流导向装置，增加了血管内治疗的普及。然而，血管内治疗鞍旁动脉瘤并非没有程序风险，与不完全动脉瘤闭塞和复发率较高有关，并且可能无法解决手术减压可以解决的视神经压迫症状。因此，越来越多的血管内治疗鞍旁动脉瘤应该通过与手术基准的比较来证明是合理的。因此，作者进行了这项研究，以确定最常见的鞍旁动脉瘤类型：眼动脉（OphA）动脉瘤的患者、视觉和动脉瘤结局。
方法
回顾性分析了 198 例患者的 208 例 OphA 动脉瘤的显微夹闭结果。记录并分析了患者人口统计学、动脉瘤形态（大小、钙化等）、临床特征和患者结局。
结果
尽管这些动脉瘤中有 20%的体积较大或巨大，但在 208 例病例中，91%的动脉瘤完全闭塞，99.5%的 OphA 保持通畅。动脉瘤复发率为 3.1%，再治疗率为 0%。总体而言，96.2%的患者和所有 156 例未破裂动脉瘤患者均获得良好结局（改良 Rankin 量表评分 0-2）。8 例（3.8%）患者出现新的视野缺损（偏盲或象限盲），5 例（2.4%）患者视力下降，9 例（4.3%）患者单眼失明。在 17 例术前有视力缺损的患者中，9 例（52.9%）视力改善。
结论
夹闭 OphA 动脉瘤最相关的风险是新的视力缺损。在前床突切除术、动脉瘤解剖和夹闭应用过程中需要精细的显微技术，以优化视力结局，术后积极的药物治疗可能潜在降低迟发性视力缺损的发生率。随着血管内治疗特别是血流导向装置的结果变得已知，它们需要与这些手术基准进行比较，以确定最佳实践。
