CONTRALATERAL AND IPSILATERAL MICROSURGICAL APPROACHES TO CAROTID-OPHTHALMIC ANEURYSMS

OBJECTIVE: The vicinity of carotid-ophthalmic aneurysms to the roof of the cavernous sinus, to the anterior clinoid process, and to the opti c nerve or the optic chiasm requires well-defined surgical techniques. Although microsurgical techniques with ipsilateral direct approaches to these aneurysms have been described in detail, studies about contra lateral strategies for the microsurgical treatment of carotid-ophthalm ic aneurysms are rare and are mainly confined to case reports. The aim of this study is to describe how to decide on the ipsilateral and con tralateral microsurgical approaches to such aneurysms and to demonstra te the surgical techniques for the ipsilateral and contralateral expos ure of carotid-ophthalmic aneurysms. METHODS: In a series of 51 patien ts with 58 aneurysms of the ophthalmic segment of the internal carotid artery, nine patients with 10 aneurysms (4 large aneurysms, 6 small a neurysms) were treated via a contralateral microsurgical approach afte r careful preoperative planning. Preoperative planning was based on th e analysis of clinical and radiographic data, including cranial comput ed tomography, magnetic resonance imaging, magnetic resonance angiogra phy, and conventional cerebral angiography. RESULTS: The postoperative results were good in 38 (75%) of the patients, fair in 2 (4%), and po or in 3 (6%); 8 (15%) of the patients died after surgery. The postoper ative follow-up was 4 months to 10 years. Postoperatively, 15 of 19 pa tients with uni- or bilateral visual deficits or visual field defects improved, 3 of the 19 patients experienced postoperative impairment of visual function, and 1 of the 19 patients had an unchanged visual fie ld deficit. Visual impairment or unchanged visual function was observe d in patients who underwent ipsilateral approaches, which was possibly caused by inappropriate intraoperative retraction of the optic nerve or chiasm. In all patients presenting with preoperative visual deficit s who were treated via contralateral approaches, visual function impro ved in the postoperative course. CONCLUSION: Giant carotid-ophthalmic aneurysms that are eligible for surgical treatment as well as small an d large aneurysms dislocating the optic nerve or the chiasm superomedi ally or medially should be approached via ipsilateral craniotomies. It is recommended that small and large aneurysms of the carotid-ophthalm ic segment originating medially, superomedially, or superiorly, displa cing the optic nerve or the chiasm superiorly, superolaterally, or lat erally, be approached via contralateral craniotomies.