Elsevier

World Neurosurgery

Volume 114, June 2018, Pages e861-e868
World Neurosurgery

Original Article
Entire Orifice Blocking-Assisted Microsurgical Treatment: Clipping of Intracranial Giant Wide-Neck Paraclinoid Aneurysms

https://doi.org/10.1016/j.wneu.2018.03.101Get rights and content

Highlights

  • This is so far the largest study about entire orifice blockade (EOB) assistant clipping technique.

  • All subjects had giant wide-neck paraclinoid aneurysms.

  • EOB is safe and effective for the treatment of giant wide-neck paraclinoid aneurysms.

Objective

Giant wide-neck paraclinoid aneurysms remain a formidable challenge for neurosurgeons due to the brisk retrograde blood flow during surgical clipping. Theoretically, Entire orifice blockade (EOB) by placing a longitudinal intracarotid balloon catheter across the aneurysm neck could achieve a good vascular control in treating cerebral aneurysms, but related studies have been scarce. The aim of this study was to evaluate the safety and efficiency of the EOB-assisted microsurgical technique for treating giant wide-neck paraclinoid aneurysms.

Methods

Clinical data and treatment summaries of patients with giant wide-neck paraclinoid aneurysms who underwent EOB-assisted microsurgical clipping were retrospectively reviewed.

Results

A total of 26 patients were analyzed. All but 3 patients harbored unruptured aneurysms. The mean largest diameter of the aneurysms was 26.8±2.0 mm, and the mean neck size was 12.5±2.4 mm. All lesions were successfully clipped without residual aneurysms. Post-operative images revealed no major branch occlusion due to thromboembolic complications. Four patients presented neurologic deficits caused by vasospasm, 3 of which were completely resolved by postoperative treatment. At a mean follow-up time of 1.86 ± 0.95 years (range, 0.5–3.5 years), none of the patients died, and 96.2% (n = 25) of the patients had favorable clinical outcomes with modified Rankin Scale values of 0–2.

Conclusions

For patients with giant wide-neck paraclinoid aneurysms, EOB-assisted microsurgical clipping is a safe and useful procedure for obtaining vascular control, for softening and shrinking the aneurysm sac and for providing a wide and clean operative field that allows the clip to be effectively placed.

Introduction

Giant wide-neck aneurysms arising from the paraclinoid segment of the internal carotid artery (ICA) commonly manifest with visual impairment, and they always require microsurgical clipping surgeries to reduce the mass effect.1, 2, 3 Because the retrograde blood flow through the surrounding arteries and cavernous branches is brisk, clipping these aneurysms often requires the temporary influence of local circulation.4, 5 Many previous studies have reported formidable challenges related to acquiring proximal control, achieving safe intracranial exposure, preventing intraoperative rupture, and reducing complications such as clip slippage or the occlusion of the parent artery and perforators.6, 7, 8 Because of these challenges, the mortality rate remains high and neurologic prognoses are poor in patients with these lesions.9, 10, 11, 12, 13

Theoretically, among the current vascular control methods, entire orifice blockade (EOB) of the aneurysm by placing a longitudinal intracarotid balloon catheter across the aneurysm neck can achieve a more controlled temporary blockade of aneurysmal flow and decompression. This technique was first introduced by Thorell et al.14 They described 4 cases of complex paraclinoid aneurysms in which relatively long and flexible ellipsoid balloons were used to assist with clipping. Another study, published by Steiger et al., reported 2 cases of giant paraclinoid aneurysms that were treated with EOB. The results of their study, which supported Thorell's conclusion, showed that all the aneurysms were completely occluded and that no complications were related to the endovascular procedure.15 However, because the sample sizes reported in these studies are small, and there is a shortage of other related studies, assessing the complications and long-term prognoses associated with the use of EOB remains difficult. Moreover, neither study focused on giant wide-neck aneurysms in the paraclinoid region. Here, we raised the following question for the first time: Does EOB provide special advantages as a treatment for this kind of lesion?

In the present study, we aimed to evaluate the safety and efficacy of EOB-assisted direct microsurgical clipping performed using a long and flexible balloon. To achieve this aim, we summarize the currently available medical data related to patients with giant wide-neck paraclinoid aneurysms who were treated with this technique.

Section snippets

Study Design and Participants

In this study, we retrospectively analyzed patients with giant wide-neck ICA paraclinoid aneurysms who were treated at our institution from January 2014 to March 2017. The following inclusion criteria were applied: patients with ICA paraclinoid aneurysms diagnosed with digital subtraction angiography (DSA) or computed tomography angiography (CTA); patients with giant (largest dimension >2.5 cm) and wide-neck aneurysms (dome-to-neck ratio <2.0 or neck size >4 mm); patients treated with

Patient Characteristics

Data from 26 patients were reviewed retrospectively. The mean age was 41.3 ± 9.5 years; 46.2% of patients (n = 12) were male; and 26.9% (n = 7), 3.8% (n = 1), 7.7% (n = 2) and 15.4% (n = 4) of patients had a history of hypertension, diabetes mellitus, coronary artery disease, and hypercholesterolemia, respectively. At the time of onset, 34.6% of the patients (n = 9) were smokers, and 30.8% of them (n = 8) consumed alcohol. The mean time of stay in the ICH was 4.4 ± 4.1 days, and the mean length

Discussion

Paraclinoid, wide-neck giant aneurysms can be difficult because of their large size, wide neck, and complicated relationships with surrounding neurovascular structures.5, 9, 18, 19 Because of the large amount of retrograde blood flow, proximal and distal temporary clipping of the parent artery is often used to soften the aneurysm sac. However, in some cases, even when clinoidectomy is performed and the extradural intracavernous ICA exposed, it may still be difficult to achieve proximal control.

Conclusion

The results of the present study demonstrate that EOB-assisted microsurgical clipping is a safe and useful procedure for obtaining vascular control, for softening and shrinking the aneurysm sac, and for providing a wide and clean operative field that allows the clip to be placed effectively in patients with giant wide-neck paraclinoid aneurysms.

Acknowledgments

The authors thank Guo Rui, a medical student from Capital Medical University (China, Beijing), for his schematic diagram of the EOB-assisted microsurgical clipping technique.

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  • Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

    Ruiqui Chen and Rui Guo contributed equally to the manuscript.

    This work was supported by the Fundamental Research Funds for Central Universities (2012017yjsy200).

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