Abstract
Background
Clipping continues to be one of the treatment strategies for ophthalmic artery aneurysms not amenable for stenting or coiling, or when long-term treatment durability is a concern. However, crescent development of endovascular techniques demands minimal invasiveness in the transcranial approaches while ensuring satisfactory results.
Methods
We describe an extradural micropterional keyhole approach (eMKA) to the paraclinoid region and highlight the key anatomical elements of this surgical approach.
Conclusion
The eMKA is a minimally invasive approach that provides access to the paraclinoid region using an extradural corridor. Therefore, it is suitable for clipping of ophthalmic artery aneurysms and other paraclinoid aneurysms.
Similar content being viewed by others
Abbreviations
- ACP:
-
anterior clinoid process
- eMKA:
-
extradural micropterional keyhole approach
- MOB:
-
meningo-orbital band
References
Beretta F, Andaluz N, Zuccarello M (2004) Aneurysms of the ophthalmic (C6) segment of the internal carotid artery: treatment options and strategies based on a clinical series. J Neurosurg Sci 48(4):149–156
Iwasaki K, Toda H, Hashikata H, Goto M, Fukuda H (2018) Extradural anterior clinoidectomy and optic canal unroofing for paraclinoid and basilar aneurysms: usefulness of a no-drill instrumental method. Acta Neurochir Suppl 129:39–42
Martínez-Pérez R, Hernández-Álvarez V, Maturana R, Mura JM (2019) The extradural minipterional pretemporal approach for the treatment of spheno-petro-clival meningiomas. Acta Neurochir. https://doi.org/10.1007/s00701-019-04064-3
Martinez-Perez R, Joswig H, Albiña P, Perales I, Poblete T, Mura J (2019) The extradural minipterional approach for the treatment of paraclinoid aneurysms: a cadaver step-wise dissection and clinical case series. Neurosurg Rev. https://doi.org/10.1007/s10143-019-01219-9
Matsuo S, Komune N, Tsuchimochi R, Kai Y, Matsumoto K, Haga S, Inoue T (2018) The microsurgical relationships between internal carotid-posterior communicating artery aneurysms and the skull base. J Neurol Surg B Skull Base 79(5):427–436
Mattingly T, Kole MK, Nicolle D, Boulton M, Pelz D, Lownie SP (2013) Visual outcomes for surgical treatment of large and giant carotid ophthalmic segment aneurysms: a case series utilizing retrograde suction decompression (the “Dallas technique”). J Neurosurg 118(5):937–946
Moroi J, Hadeishi H, Suzuki A, Yasui N (2005) Morbidity and mortality from surgical treatment of unruptured cerebral aneurysms at research Institute for Brain and Blood Vessels-Akita. Neurosurgery 56(2):224–231 discussion 224-231
Noguchi A, Balangisam V, Shiokawa Y, McMenomey SO, Delashaw JB (2005) Extradural anterior clinoidectomy. Technical note. J Neurosurg 102(5):937–946
Welling LC, Figueiredo EG, Wen HT, Gomes MQT, Bor-Seng-Shu E, Casarolli C, Guirado VMP, Teixeira MJ (2015) Prospective randomized study comparing clinical, functional, and aesthetic results of minipterional and classic pterional craniotomies. J Neurosurg 122(5):1012–1019
Yasargil MG, Fox JL (1975) The microsurgical approach to intracranial aneurysms. Surg Neurol 3(1):7–14
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.
Additional information
Key points
• As a minimally invasive approach, the eMKA reduces operative times and risk of infection, while offers excellent cosmetic results [9].
• Section of the MOB and the middle fossa minipeeling are key for enabling the extradural corridor and perform an extradural clinoidectomy.
• Use of the extradural corridor exponentially increases the surgical maneuverability around the paraclinoid region in an eMKA, while reduces brain retraction and potential venous injury, since minimal Sylvian dissection is required.
• Removal of the ACP using no-drilling techniques is safe and reduces the risk of optic nerve heat injury.
• Opening the distal ring is essential in carotid-ophthalmic aneurysms, as it facilitates supraclinoid ICA mobilization and provides intracranial proximal control (Fig. 6).
• For superiorly pointing aneurysms, laterally curved low profile clips are preferred for avoiding any contact between the clip and the optic nerve.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This manuscript has not been previously published in whole or in part or submitted elsewhere for review.
This article is part of the Topical Collection on Vascular Neurosurgery - Aneurysm
Electronic supplementary material
0:17, keyhole craniectomy; 0:24, sphenoid wing drilling; 0:34, partial orbitotomy; 0:48, division of the meningo-orbital band; 0:57, minipeeling of the middle fossa; 1:04, optic canal decompression; 1:28, removal of the anterior clinoid process; 1:42, dural opening; 1:56, section of the distal dural ring; 2:10, opening of the opticocarotid cistern; 2:26, aneurysm dissection; 2:42, aneurysm clip placement; 3:00, video ICG-angiography; 3:20, closure. (ICA = internal carotid artery) (MP4 309,548 kb)
Rights and permissions
About this article
Cite this article
Martinez-Perez, R., Jusue-Torres, I., Chiarullo, M. et al. Surgical clipping of a non-ruptured ophthalmic aneurysm through an extradural micropterional keyhole approach. Acta Neurochir 162, 917–921 (2020). https://doi.org/10.1007/s00701-020-04261-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00701-020-04261-5