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Surgical clipping of a non-ruptured ophthalmic aneurysm through an extradural micropterional keyhole approach

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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.

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Abbreviations

ACP:

anterior clinoid process

eMKA:

extradural micropterional keyhole approach

MOB:

meningo-orbital band

References

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Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Rafael Martinez-Perez.

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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.

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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)

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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

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  • DOI: https://doi.org/10.1007/s00701-020-04261-5

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