A combined microsurgical skull-base and endovascular approach to giant andlarge paraclinoid aneurysms

BACKGROUND The treatment of giant and large paraclinoid aneurysms remains challenging. To improve exposure, facilitate the dissection of aneurysms, assure vascul ar control, reduce brain retraction and temporary occlusion time, enable si multaneous treatment of associated lesions, and achieve more successful tre atment of "difficult" (atherosclerotic and calcified) aneurysms, we combine d the skull-base approach with endovascular balloon occlusion of the intern al carotid artery (ICA) and suction decompression of the aneurysm. METHODS Sixteen female patients were treated, eight with giant aneurysms and eight with large aneurysms. Eight aneurysms occurred on the right side and eight on the left. Eight patients had an additional aneurysm; five were clipped d uring the same procedure. Three patients had infundibular arterial dilation . One patient had an associated hemangioma of the ipsilateral cavernous sin us. The cranio-orbital-zygomatic approach was used for all patients. The an terior clinoid was drilled, and the optic nerve was decompressed, dissected , and mobilized. Transfemoral temporary balloon occlusion of the ICA in the neck was followed by placement of a temporary clip proximal to the posteri or communicating artery. Suction decompression was then applied. All aneury sms were then successfully clipped, except one that had a calcified neck an d wall that could not be collapsed. Intraoperative angiography performed in 13 of 15 patients with clipped aneurysms confirmed obliteration of the ane urysm and patency of the blood vessels. RESULTS Postoperative results were good in 14 patients. One patient had right-sided hemiplegia and expressive aphasia, which improved after rehabilitation. On e patient with an additional basilar tip aneurysm clipped simultaneously di ed on the fifth postoperative day because of intraventricular hemorrhage. T he origin of bleeding could not be determined on autopsy. Surgical difficul ties and morbidity stemmed mainly from a severely calcified or atherosclero tic aneurysmal neck. CONCLUSION The combination of skull-base approaches and endovascular balloon occlusion coupled with suction decompression is a successful option for the treatmen t of these challenging aneurysms. (C) 1998 by Elsevier Science Inc.