Cerebrovascular Neurosurgery Department, Swedish Neuroscience Institute, Seattle, WA 98122, USA.
Department of Neurological Surgery, Hospital San Fernando, Buenos Aires 1646, Argentina.
Medicina (Kaunas). 2021 Jul 19;57(7):731. doi: 10.3390/medicina57070731.
Tandem intracranial aneurysms (TandIAs) are rare but inherently complex, and special technical considerations are required for their surgical management. The present case highlights the key surgical aspects of two carotid-ophthalmic TandIAs incidentally found in a 60-year-old female. Both the aneurysms were superiorly projecting, regular in size, and involved the left ophthalmic segment of the internal carotid artery (ICA). The minimum distance between the necks was 3 mm. The patient underwent microsurgery because of the reported major complications rate of the endovascular treatment in the case of a very short minimum distance between the TandIAs. After cervical ICA exposure, both the aneurysms were excluded through a pterional approach. Intradural anterior clinoidectomy and unroofing of the optic canal allowed the mobilization of the left optic nerve. The more distal aneurysm was clipped before the opening of the distal dural ring of the ICA. The proximal aneurysm was clipped with two straight clips stacked perpendicular to the ICA. A small remnant was intentionally left to avoid the stenosis of the ophthalmic artery. Postoperative angiography showed the exclusion of both the aneurysms with a small dog-ear of the more proximal one. The patient was discharged neurologically intact and, after one year, the remnant remained stable. Microsurgical clipping is a definitive and durable treatment for carotid-ophthalmic TandIAs. In the case of a very short minimum distance between the aneurysms, the distal one should be clipped first to make the anterior clinoidectomy, opening of the distal dural ring of the ICA, and clipping of the more proximal aneurysm easier.
串联性颅内动脉瘤（TandIAs）较为罕见，但具有内在的复杂性，因此需要特殊的技术考虑来进行手术管理。本病例重点介绍了一位 60 岁女性患者偶然发现的两个颈内动脉-眼动脉串联性颅内动脉瘤的关键手术方面。两个动脉瘤均向上突出，大小规则，累及左侧颈内动脉眼段。瘤颈之间的最小距离为 3 毫米。由于报告称在 TandIAs 之间非常短的最小距离情况下，血管内治疗的并发症发生率较高，因此患者选择接受显微手术。在颈内动脉暴露后，通过翼点入路排除了两个动脉瘤。硬脑膜内前床突切除术和视神经管开窗术使左侧视神经得以移动。在打开颈内动脉远端硬脑膜环之前夹闭了更远端的动脉瘤。近端动脉瘤使用两个垂直于颈内动脉放置的直夹夹闭。故意留下一小部分残余瘤颈以避免视神经动脉狭窄。术后血管造影显示两个动脉瘤均被排除，近端动脉瘤有一小部分残余。患者神经功能完整出院，一年后残余瘤颈稳定。显微手术夹闭是治疗颈内动脉-眼动脉串联性颅内动脉瘤的一种明确且持久的治疗方法。在动脉瘤之间非常短的最小距离的情况下，应首先夹闭远端动脉瘤，以便进行前床突切除术、打开颈内动脉远端硬脑膜环和夹闭近端动脉瘤。
