Gandhi Sirin, Mascitelli Justin R, Zhao Xiaochun, Chen Tsinsue, Hardesty Douglas A, Wright Ernest J, Lawton Michael T
Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
Oper Neurosurg. 2019 Sep 1;17(3):E110-E111. doi: 10.1093/ons/opy383.
Ophthalmic segment aneurysms (OSAs) are technically challenging lesions with a wide-neck morphology and proximity to the optic nerve. Revascularization and aneurysm trapping are occasionally needed to manage unclippable OSAs. Microsurgical treatment requires anterior clinoidectomy, optic strut drilling, and proximal/distal dural ring dissection for adequate exposure. This video demonstrates a two-stage revascularization and clip reconstruction of an OSA. A 62-yr-old woman was presented, with acute-onset expressive aphasia, right hemineglect, and hemiparesis. Neuroimaging revealed a partially thrombosed giant OSA measuring 2.5 × 2.3 cm2. Patient consent was obtained for bypassing, trapping, and decompressing the aneurysm. A pterional craniotomy was performed and an external carotid artery - radial artery graft - middle cerebral artery bypass was performed. The aneurysm was proximally occluded with a permanent clip on the clinoidal internal carotid artery (ICA). Adherence of the distal supraclinoid ICA to the aneurysm wall did not allow for aneurysm trapping. On postoperative day 8, the patient experienced acute mental status decline due to a frontal intraparenchymal hemorrhage. The aneurysm was trapped in a second surgery to occlude persistent retrograde aneurysm filling. The aneurysm sac was circumferentially dissected with temporary parent artery trapping. The OSA was opened and thrombectomized using an ultrasonic aspirator followed by trapping clip application. Postoperatively, the patient gradually returned to neurological baseline with minimal expressive aphasia. Although OSAs are preferentially treated with flow diversion, giant OSAs with significant mass effect may necessitate microsurgical clipping or trapping with decompressive thrombectomy. This case demonstrates that proximal clip occlusion may not be sufficient for aneurysm thrombosis and rupture prevention. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
眼动脉段动脉瘤（OSA）在技术上是具有挑战性的病变，其具有宽颈形态且靠近视神经。对于无法夹闭的OSA，有时需要进行血管重建和动脉瘤夹闭术。显微手术治疗需要进行前床突切除术、视神经管减压术以及近端/远端硬脑膜环分离以获得充分暴露。本视频展示了一例OSA的两阶段血管重建和夹子重建。一名62岁女性患者，出现急性起病的表达性失语、右侧偏侧忽视和偏瘫。神经影像学检查发现一个部分血栓形成的巨大OSA，大小为2.5×2.3平方厘米。已获得患者对动脉瘤旁路、夹闭和减压的同意。进行了翼点开颅术，并实施了颈外动脉-桡动脉移植-大脑中动脉旁路手术。在床突段颈内动脉（ICA）上用永久性夹子近端夹闭动脉瘤。床突上段ICA远端与动脉瘤壁粘连，无法进行动脉瘤夹闭。术后第8天，患者因额叶脑实质内出血出现急性精神状态下降。在第二次手术中夹闭动脉瘤以闭塞持续的逆行动脉瘤充盈。使用临时阻断载瘤动脉对动脉瘤囊进行环形分离。打开OSA，使用超声吸引器进行血栓切除术，随后应用夹闭夹。术后，患者逐渐恢复至神经功能基线，仅遗留轻微的表达性失语。尽管OSA优先采用血流导向治疗，但具有显著占位效应的巨大OSA可能需要显微手术夹闭或夹闭并减压性血栓切除术。本病例表明，近端夹闭可能不足以防止动脉瘤血栓形成和破裂。经亚利桑那州凤凰城巴罗神经学研究所许可使用。
