Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
World Neurosurg. 2022 Jul;163:40. doi: 10.1016/j.wneu.2022.04.003. Epub 2022 Apr 8.
Giant paraclinoid internal carotid artery (ICA) aneurysms are surgically challenging, mainly owing to lack of adequate working space and distortion of the regional anatomy. Anterior clinoidectomy is a vital surgical technique in such cases, allowing optic nerve decompression and exposure of the proximal ICA outside the confines of the arachnoid. While clinoidectomy is generally conducted intradurally, some aneurysms, particularly unruptured and directed medially paraclinoid ICA aneurysms, can allow a completely extradural clinoidectomy. Extradural clinoidectomy avoids bone dust spillage and drill bit-related injury from prolonged intradural drilling times. An 18-year-old man with a giant left superior hypophyseal artery aneurysm presented with progressive headache and visual diminution. He had a very good cross-flow from the contralateral ICA and tolerated balloon test occlusion. The aneurysm was exposed after extradural clinoidectomy and optic nerve mobilization. It was a wide-necked aneurysm and involved the distal dural ring. Owing to intraoperative somatosensory evoked potential findings as well as our concern of inadequate neck occlusion in view of the distal dural ring involvement and a possible future aneurysm regrowth, we trapped the aneurysm. The patient made an uneventful recovery with improvement in vision and normal visual fields. This video demonstrates the feasibility and utility of extradural clinoidectomy in adequate exposure of giant paraclinoid aneurysms and the role of aneurysm trapping for definitive aneurysm obliteration when the distal dural ring is involved. Trapping, in contrast to direct clipping, avoids manipulation of the compressed optic nerves, which is necessary for an optimal environment for postoperative visual recovery.
巨大的颈内动脉岩骨段动脉瘤（ICA）手术难度大，主要是由于缺乏足够的操作空间和区域解剖结构的扭曲。在前床突切除术是这种情况下的重要手术技术，允许视神经减压和暴露ICA 近端在蛛网膜的限制之外。虽然通常在硬脑膜内进行前床突切除术，但有些动脉瘤，特别是未破裂和向内侧的颈内动脉岩骨段动脉瘤，可以进行完全硬膜外前床突切除术。硬膜外前床突切除术避免了骨屑溢出和钻头相关的损伤，因为长时间的硬脑膜内钻孔。一名 18 岁男性，患有巨大的左侧垂体上动脉动脉瘤，表现为进行性头痛和视力减退。他有很好的对侧颈内动脉的交叉血流，并且能够耐受球囊测试闭塞。在硬膜外前床突切除和视神经松解后暴露了动脉瘤。这是一个宽颈动脉瘤，涉及硬膜下环的远端。由于术中体感诱发电位的发现，以及我们考虑到远端硬膜环的受累和可能未来的动脉瘤复发，颈内动脉的狭窄不足以进行闭塞，因此我们对动脉瘤进行了夹闭。患者恢复顺利，视力改善，视野正常。该视频演示了硬膜外前床突切除术在充分暴露巨大颈内动脉岩骨段动脉瘤中的可行性和实用性，以及在涉及远端硬膜环时，动脉瘤夹闭对于明确的动脉瘤闭塞的作用。夹闭与直接夹闭不同，避免了对受压视神经的操作，这对于术后视力恢复的最佳环境是必要的。
