Results after surgical and endovascular treatment of paraclinoid aneurysmsby a combined neurovascular team

OBJECTIVE: Advances in surgical and endovascular techniques have improved t reatment for paraclinoid aneurysms. A combined surgical and endovascular te am can formulate individualized treatment strategies for patients with para clinoid aneurysms. Patients who are considered to be at high surgical risk can be treated endovascularly to minimize morbidity. We reviewed the clinic al and radiographic outcomes of 238 paraclinoid aneurysms treated by our co mbined surgical and endovascular unit. METHODS: From 1991 to 1999, the neurovascular team treated 238 paraclinoid aneurysms in 216 patients at the Massachusetts General Hospital. The modali ty of treatment for each aneurysm was chosen based on anatomic and clinical risk factors, with endovascular treatment offered to patients considered t o have higher surgical risks. One hundred eighty aneurysms were treated by direct surgery, 57 were treated by endovascular occlusion, and one was trea ted by surgical extracranial-intracranial bypass and endovascular internal carotid artery balloon occlusion. Locations were transitional, 12 (5%); car otid cave, 11 (5%); ophthalmic, 131 (55%); posterior carotid wall, 38 (16%) ; and superior hypophyseal 46 (19%). Lesions contained completely within th e cavernous sinus were excluded from this analysis. RESULTS: Using the Glasgow Outcome Scale (GOS), overall clinical outcomes w ere excellent or good (GOS 5 or 4), 86%; fair (GOS 3), 7%; poor (GOS 2), 4% ; and death (GOS 1), 3%. Among the surgically treated patients, 90% experie nced excellent or good outcomes (GOS 5 or 4), 6% had fair outcomes (GOS 3), 2% had poor outcomes (GOS 2), and 3% died (GOS 1). Among the endovascularl y treated patients, 74% had excellent or good outcomes (GOS 5 or 4), 12% ha d fair outcomes (GOS 3), 10% had poor outcomes (GOS 2), and 4% died (GOS 1) . The overall major and minor complication rate from surgery was 29%, with a 6% surgery-related permanent morbidity rate and a mortality rate of 0%. T he overall major and minor complication rate from endovascular treatment wa s 21%, with a 3% endovascular-related permanent morbidity rate and a 2% mor tality rate. Visual outcomes for patients who presented with visual symptom s were as follows: improved, 69%; no change, 25%; worsened, 6%; and new vis ual deficits, 3%. In general, angiographic efficacy was lower in the endova scular treatment group. CONCLUSION: A combined team approach of direct surgery and endovascular coi ling can lead to good outcomes in the treatment for paraclinoid aneurysms, including high-risk lesions that might not have been treated in previous su rgical series.