Contralateral Mini Craniotomy for Clipping of Bilateral Ophthalmic Artery Aneurysms Using Unilateral Proximal Carotid Control and Sugita Head Frame

doi:10.1016/j.wneu.2010.06.028

World Neurosurgery

Volume 75, Issue 1, January 2011, Pages 78-82

https://doi.org/10.1016/j.wneu.2010.06.028 Get rights and content

Objective

Conventional surgical treatment of bilateral ophthalmic aneurysms would require bilateral craniotomies and bilateral neck dissections for proximal control of the cervical internal carotid artery (ICA). We present a semiemergent case where bilateral ophthalmic artery aneurysms were clipped using a unilateral mini-pterional craniotomy and contralateral proximal cervical ICA control while employing the Sugita head frame.

Clinical Presentation

A 37-year-old female presented with progressive right retro-orbital headaches. MRI/A revealed a right carotid–ophthalmic aneurysm as well as a small aneurysm on the left carotid–ophthalmic segment. Given the young age and medial orientation of the right aneurysm, direct surgical clipping was planned. It was our thought that a contralateral approach would afford us the best chance to clip the right medially pointing aneurysm fully without optic nerve retraction while having proximal control via exposure of contralateral cervical ICA.

Methods

After gaining proximal ICA control from right neck dissection, the Sugita frame was rotated to allow for a left pterional craniotomy. The right medially pointing ophthalmic aneurysm was clipped without optic nerve retraction. After dissection of the distal dural ring and gaining proximal control, the left aneurysm was clipped. Postoperatively, the patient remained intact without any visual complaints, and both aneurysms were obliterated on angiography.

Conclusion

Our case illustrates safety and control while clipping bilateral ophthalmic artery aneurysms via a unilateral mini-pterional approach and utility of the Sugita head frame.

Section snippets

Objective

Conventional surgical treatment of bilateral ophthalmic aneurysms, especially those with rupture, require bilateral craniotomies and potentially bilateral neck dissections for proximal control of cervical internal carotid artery (ICA). We present a semiemergent case where bilateral ophthalmic artery aneurysms were clipped using a unilateral mini-pterional craniotomy and contralateral proximal cervical ICA control while employing the Sugita head frame.

Clinical Presentation

A 37-year-old woman presented with progressive right retroorbital headaches. MRI/A revealed an incidental right carotid–ophthalmic aneurysm as well as a small aneurysm on the left carotid-ophthalmic segment. Aside from headaches, the patient was neurologically intact, with no visual complaints. Both endovascular and surgical treatments were thoroughly considered for this patient, but given the young age and medial orientation of the right aneurysm, direct surgical clipping was considered. It

Materials and Methods

A previously healthy 37-year-old woman presented with progressive headaches especially in the right retroorbital area. MRI revealed an ICA aneurysm. Formal four-vessel angiography revealed bilateral ophthalmic segment aneurysms with the right side larger than the left (Figure 1). Initial plan was to surgically treat the medially pointing right sided aneurysm. Rather than proceed with a right-sided craniotomy, we felt that given the orientation of the aneurysm, a contralateral approach would be

Results

The patient continued to do well 1 month after surgery and has had no visual or neurologic deficits.

Discussion

Our case illustrates the efficacy and safety of clipping bilateral ophthalmic aneurysms using a unilateral approach while achieving proximal control of ICA at the neck. Prior reports of contralateral approach have scantily discussed neck dissection for proximal control. We were able to utilize the Sugita head frame to rotate the head with great ease for dissection of both aneurysms and perform contralateral neck dissection for proximal control.

Yasargil et al. pioneered the contralateral

Conclusion

Our case illustrates safety and control in clipping bilateral ophthalmic artery aneurysms via a unilateral mini-pterional approach. The aneurysms were completely obliterated, which obviated the need for a second craniotomy. It is paramount for a vascular neurosurgeon to be creative and offer innovative minimally invasive approaches to patients, especially in an era of many endovascular options.

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Cited by (14)

Comprehensive Anatomic Assessment of Ipsilateral Pterional Versus Contralateral Subfrontal Approaches to the Internal Carotid Ophthalmic Segment: A Cadaveric Study and Three-Dimensional Simulation
2019, World Neurosurgery
Medially pointing aneurysms of the ophthalmic segment of the internal carotid artery (oICA) represent a neurosurgical challenge. Conventional ipsilateral approaches require internal carotid artery and optic nerve (ON) mobilization as well as anterior clinoidectomy (AC), all associated with increased surgical risk. Contralateral approaches could provide a better exposure of the superomedial aspect of the oICA, ophthalmic artery, and superior hypophyseal artery, sparing AC and internal carotid artery or ON mobilization. However, the microsurgical anatomy of this approach has not been systematically studied. In the present work, we exhaustibly analyzed the anatomic and morphometric characteristics of contralateral approaches to the oICA and compared them with those from ipsilateral approaches.
We assessed 36 ipsilateral and contralateral approaches to the oICAs in cadaveric specimens and live patients, using for the latter a three-dimensional virtual reality (VR) system.
Contralateral approaches spared sylvian fissure dissection and required only minimal frontal lobe retraction. The ipsilateral and contralateral oICA were found at a depth of 49.2 ± 1.8 mm (VR, 50.1 ± 2.92 mm) and 65.1 ± 1.5 mm (VR, 66.05 ± 3.364 mm) respectively. The exposure of the superomedial aspect of oICA was 7.25 ± 0.86 mm (VR: 6 ± 1 mm) contralaterally without ON mobilization and 2.44 ± 0.51 mm (VR, 2 ± 1 mm) ipsilaterally even after AC. Statistical analysis showed that, for nonprefixed chiasm, contralateral approaches achieved a significantly higher exposure of the ophthalmic artery, superior hypophyseal artery, and the superomedial aspect of the oICA with its perforating branches (all P < 0.01).
Contralateral approaches may enable successful exposure of the oICA and related vascular structures, reducing the need for AC or ON mobilization. Systematic clinical/surgical studies are needed to further determine the effectiveness and safety of the approach.
Contralateral Approach Based on a Preoperative 3-Dimensional Virtual Osteotomy Technique for Anterior Circulation Aneurysms
2019, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Although the preoperative simulation showed that proximal ICA control can be gained from intracranial segment, if the clinoid space is narrow, when necessary, resecting the ACP is still needed. Therefore, to be on the safe side, exposure of cervical segment to gain proximal ICA control from the ipsilateral side of the aneurysm before craniotomy should be performed first.15 Two cases (11 and 13) were accidentally discovered contralateral aneurysms during the examination of tumor lesions.
Objective: Our objective was to review 15 consecutive patients with anterior circulation aneurysms managed through a contralateral approach. Individualized surgical simulation using three-dimensional (3D) imaging was adopted to enable safe performance of clipping surgery. Methods: Five patients had multiple intracranial aneurysms, and 10 patients had a single aneurysm on the contralateral side of the craniotomy. Preoperatively, the unique architecture of aneurysms was fully understood in their 3-dimensionality reconstructed by Mimics software. The location of the cranial bone window and the patient's head position was individually optimized using a preoperative simulation system. Results: In this cohort, 17 contralateral aneurysms showed no wall calcifications. Projections of the aneurysms were superomedial (3/17, 17.6%), medial (8/17, 47.1%), posterior (3/17, 17.6%), and superior (3/17, 17.6%).
The visual similarity between the simulating scene and the operative view was excellent in 100% of the cases. Four patients were treated with a contralateral pterional approach, and the remaining 11 patients were treated with a contralateral supraorbital keyhole approach. All of them were well-clipped, except 1 blister-like aneurysm being wrapped. All 15 patients had good outcomes (mRS ≤ 3) after a mean 13 months follow-up. There were no recurrences after surgical treatment. Conclusions: The contralateral approach for the selected anterior circulation aneurysms is feasible in experienced hands with acceptable morbidity. This approach should be the choice only under judicious case-to-case planning based on a preoperative 3D virtual osteotomy technique.
Minimally Invasive Alternative Approaches to Pterional Craniotomy: A Systematic Review of the Literature
2018, World Neurosurgery
Minimally invasive alternatives to the pterional craniotomy include the minipterional and the supraorbital craniotomy (SOC). The latter is performed via either an eyebrow or an eyelid skin incision. The purpose of this systematic review was to analyze the type and the incidence of approach-related complications of these so-called “keyhole craniotomies”.
We review pertinent articles retrieved by search in the PubMed/Medline database. Inclusion criteria were all full-text articles, abstracts, and posters in English, up to 2016, reporting clinical results.
A total of 105 articles containing data on 5837 surgeries performed via a minipterional or either of the 2 variants of the SOC met the eligibility criteria. Pain on mastication was the most commonly reported approach-related complication of the minipterional approach, and occurred in 7.5% of cases. Temporary palsy of the frontal branch of the facial nerve and temporary supraorbital hypesthesia were associated with the SOC eyebrow variant, and occurred in 6.5%, respectively in 3.6% of cases. Transient postoperative periorbital edema and transient ophthalmoparesis occurred in 36.8% and 17.4% of cases, respectively, when the SOC was performed via an eyelid skin incision. The risk of occurrence of the latter 2 complications was related to the removal of the orbital rim, which is an obligatory part of the SOC approach through the eyelid but optional with the SOC eyebrow variant.
Each of the 3 keyhole approaches has a specific set and incidence of approach-related complications. It is essential to be aware of these complications to make the safest individual choice.
Monolateral Pterional Keyhole Approaches to Bilateral Cerebral Aneurysms: Anatomy and Clinical Application
2017, World Neurosurgery
Citation Excerpt :
Multiple intracranial aneurysms are frequently detected in about 7%–35% patients with cerebral aneurysms,1,2 and in 20%–40% of these patients, aneurysms are located bilaterally.2,3 Bilateral craniotomies, a unilateral approach, and endovascular techniques are available for occlusive therapy of bilateral aneurysms in 1-stage or 2-stage clipping.2,4-6 Contralateral conventional craniotomies have been used in management of unruptured bilateral middle cerebral artery (MCA) aneurysms and ophthalmic artery aneurysms.2
To study the anatomy and clinical application of monolateral pterional keyhole approaches for treating bilateral cerebral aneurysms.
Twelve formalin-fixed cadaveric heads underwent right pterional keyhole approaches for management of simulative contralateral aneurysms. The length of the contralateral middle cerebral artery (MCA), distal internal carotid artery (DICA), anterior cerebral artery, and ophthalmic segment of the internal carotid artery (OICA) was recorded. The operability of contralateral aneurysms was assessed using a modified numeric grading system. A total of 16 patients (12 patients with ruptured aneurysms) with bilateral cerebral aneurysms undergoing contralateral pterional keyhole approaches were included.
The contralateral A1 segment of the anterior cerebral artery, proximal A2 segment, M1 segment of the MCA, DICA, and OICA was exposed via pterional keyhole approaches. An additional 2 mm of the OICA was exposed after incision of the falciform dural fold was completed. Contralateral aneurysms of the M1 segment (posterior), M2 segment, MCA bifurcation (inferior), A2 segment (lateral), DICA (posterior and lateral), and OICA (superior, inferior, and lateral) could not be fully exposed to perform simulated surgical clipping (operability rate <75%). A total of 36 aneurysms underwent adequate surgical clipping via unilateral pterional keyhole approaches, whereas 1 aneurysm of the A3 segment did not.
Contralateral aneurysms of the M1 segment (anterior, superior, and inferior), MCA bifurcation (superior and lateral), A1 segment, A2 segment (anterior, posterior, and medial), internal carotid artery bifurcation, DICA (anterior and medial), and OICA (medial) were fully exposed from different angles and surgical maneuvers were performed via pterional keyhole approaches, including in patients presenting with subarachnoid hemorrhage.
Keyhole Approach for Clipping Intracranial Aneurysm: Comparison of Supraorbital and Pterional Keyhole Approach
2017, World Neurosurgery
Citation Excerpt :
Typically, contralateral PComA aneurysm and OA aneurysm (Figure 6) can be clipped through the contralateral first space, but contralateral anterior choroidal artery aneurysm is often clipped through the contralateral second space. When clipping a contralateral OA aneurysm, the minimum available first space is 5.7 × 10.5 mm.19 Integrating multimodal 3D images could help the neurosurgeon resolve the problem of selecting an appropriate and effective approach (Figure 7A).
The aim of this research was to compare the functional outcome and safety between supraorbital keyhole approach (SKA) and pterional keyhole approach (PKA) for clipping intracranial aneurysms.
This is a retrospective study involving 318 patients with a total of 365 aneurysms who underwent keyhole surgery, comprising 195 cases in SKA group and 123 cases in PKA group. The outcome measures include Glasgow Outcome Scale, complete clipping rate, adverse events incidence, operation view angle, working distance, and surgical incision condition.
Of a total of 356 aneurysms that were clipped and 9 trapped, no significant difference was observed in Glasgow Outcome Scale score, adverse events incidence, or complete clipping rate between the SKA and PKA groups. The distance from skin incision to anterior clinoid process was 5.87 ± 0.24 cm in SKA and 5.12 ± 0.27 cm in PKA. The operation view angle (from midline to the operating channel in sagittal plane) was 30°–40° in the SKA group and 60°–68° in the PKA group.
Our research demonstrates that both SKA and PKA are safe and effective for most anterior circulation aneurysms and parts of posterior circulation aneurysms. The SKA exposures aneurysm better on deep and sagittal directions and is more suitable for clipping aneurysms by the contralateral approach due to the short distance. The PKA has a good exposure on the neck of aneurysm with dorsal direction of parent artery and can be used to evacuate hematoma in the temporal lobe when clipping the aneurysm. Integrating multimodal 3-dimensional images could help neurosurgeon in selecting an appropriate and effective approach.
Transient cardiac arrest induced by adenosine: A tool for contralateral clipping of internal carotid artery-ophthalmic segment aneurysms
2015, World Neurosurgery
Citation Excerpt :
One patient was lost to the 1-year follow-up (Table 3) No postoperative brain infarctions or cardiac complications were recorded. The contralateral approach for selected ICA-opht aneurysms has been widely described.1–4,6–8,12–15 Several authors have reported endovascular methods and surgical approaches to achieve proximal control of the supraclinoid ICA.1,4,25
The disadvantages of a contralateral approach (CA) include deep and narrow surgical corridors and inconsistent ability to achieve proximal control of the supraclinoid internal carotid artery (ICA). However, a CA remains as a microsurgical option for selected ICA-ophthalmic (opht) segment aneurysms.
To describe transient cardiac arrest induced by adenosine as an alternative tool to obtain proximal vascular control and soften the aneurysm sac in selected patients while performing a CA.
From January 1998 to December 2013, we retrospectively identified 30 patients with ICA-opht segment aneurysms treated through a CA. Of those, 8 patients received an intravenous bolus of adenosine to induce transient cardiac arrest for softening of the aneurysm sac. We reviewed preoperative clinical status, characteristics of the contralateral aneurysm, adenosine doses, asystole time, recovery of normal circulation, outcome, and complications.
No preoperative cardiac or pulmonary pathologies were found in the study population. All contralateral ICA-opht segment aneurysms were unruptured, small, and saccular in shape. Transient cardiac arrest was induced because it was impossible to apply a temporary clip on the parent contralateral supraclinoid ICA. The median dose of adenosine was 22.5 mg (range, 5–50 mg) and the asystole time ranged from 20 to 40 seconds. All patients (n = 8) had good postoperative outcomes. No brain infarction or cardiac complications appeared postoperatively.
In selected patients, transient cardiac arrest induced by adenosine during a contralateral approach allows a brief flow arrest and softening of the aneurysm for safer exposure and clipping.

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Peer-Review ReportContralateral Mini Craniotomy for Clipping of Bilateral Ophthalmic Artery Aneurysms Using Unilateral Proximal Carotid Control and Sugita Head Frame

Objective

Clinical Presentation

Methods

Conclusion

Section snippets

Objective

Clinical Presentation

Materials and Methods

Results

Discussion

Conclusion

Surg Neurol

Transitional cavernous aneurysms of the internal carotid artery

Neurosurgery

Interhemispheric approach for carotid-ophthalmic artery aneurysm clippingCase report

J Neurosurg

Paraclinoid carotid aneurysms: Surgical management, complications, and outcome based on a new classification scheme

Skull Base

Surgery for paraclinoidal carotid artery aneurysms

J Neurosurg

Direct attack on carotid ophthalmic and large internal carotid aneurysms

Surg Neurol

Aneurysms of the ophthalmic segmentA clinical and anatomical analysis

J Neurosurg

Dorsal internal carotid artery aneurysm: classification, pathogenesis, and surgical considerations

Neurosurg Rev

A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms

J Neurosurg

Carotid-ophthalmic aneurysms

J Neurosurg

Microsurgical treatment of ventral (paraclinoid) internal carotid artery aneurysms

Neurosurgery

Contralateral and ipsilateral microsurgical approaches to carotid-ophthalmic aneurysms

Neurosurgery

Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass

J Neurosurg

Ophthalmic segment aneurysm surgery

Neurosurgery

Management of carotid-ophthalmic aneurysms

J Neurosurg

Anterior paraclinoid aneurysms

J Neurosurg

Contralateral pterional approach to a giant internal carotid-ophthalmic artery aneurysm: technical case report

Neurosurgery

Intracranial direct operation for carotid-ophthalmic aneurysm by unroofing of the optic canal

Acta Neurochir (Wien)

Parameters for contralateral approach to ophthalmic segment aneurysms of the internal carotid artery

Neurosurgery

Anterior paraclinoid aneurysms

J Neurosurg

Peer-Review Report
Contralateral Mini Craniotomy for Clipping of Bilateral Ophthalmic Artery Aneurysms Using Unilateral Proximal Carotid Control and Sugita Head Frame