Large Ophthalmic Artery Aneurysm: Intradural Clinoidectomy and Suction Decompression Technique

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This video describes the techniques for clip ligation of large Ophthalmic Artery Aneurysm. It also reviews some of the pitfalls in assessment of small aneurysms preoperatively using the CTA. This procedure also reviews the tendence for an Intradural Clinoidectomy and Retrograde Suction-Decompression technique for aneurysmal deflation. This is a 32-year-old female, who presented with acute subarachnoid hemorrhage. The location of this large Ophthalmic artery aneurysm is apparent. The neck is very closely related to the anterior Clinoid process. Part of the aneurysm neck may actually intrude into the cavernous sinus and beyond the dural ring The CT angiogram preoperatively did not demonstrate any evidence of small MCA aneurysms. However this aneurysms were found on the postoperative angiogram after clip ligation of this Ophthalmic artery aneurysm. Again, a small aneurysms, maybe overlooked on a CT angiogram. Here's a 3D view of this large Ophthalmic artery aneurysm, broad neck and the neck is also closely related to the Ophthalmic artery origin. A part of the neck may have to be left behind to protect the Ophthalmic artery. Again further examination of the CT angiogram did not reveal any obvious aneurysm along the right MCA bifurcation This patient subsequently underwent right front temporal craniotomy. This is the lateral aspect of the Sphenoid wing located here. The dural is in size in curvilinear fashion. The anterior aspect of the Sylvian fissure is dissected. Here is the optic nerve somewhat elevated by the aneurysm. Here You can see the optic nerve is affected by the aneurysm. The falciform ligament was opened and to untether the optic nerve and expose the proximal neck of aneurysm an intradural Clinoidectomy was completed. A flap of the dural was incised and reflected posteriorly to protect the ICA and the optic nerve during drilling. Intradural clinoidectomy allows a very tailored approach for bone removal. A Cancellous bone is drilled away and a section of bone is left behind over the optic nerve and carotid artery. Here again, is unroofing the optic nerve. Direct drilling over the nerve is obviously prohibited. The anterior clinoid process is further cord out. And pulmonary irrigation is used. Next, the clinoid process is removed. Some of the bone over the area of the optic strut is also drilled away, so that the nerve and the very proximal part of the internal carotid artery is exposed. The neck of the aneurysm is very proximal along the primal crinoid ICA and therefore aggressive bone drilling was necessary to adequately expose the proximal neck of the aneurysm. We're getting close to the proximal neck of aneurysm. Here's the distal ICA. The dural is incised along the optic nerve. Carla knife is used. You can see the compression band around the nerve. This compression band was caused because of the large size of the aneurysm. See, a compression is quite impressive. A nerve is splayed over the aneurysm dome further drilling of the optic strut was necessary to expose the proximal neck of the aneurysm. Then a flap of dural is left behind over the optic nerve to protect the nerve. Further, dural opening is necessary to expose the proximal neck. Here you can see the ability to look around the anterior aspect of the neck. Here Is the span of the neck of the aneurism, the nerve is carefully mobilized. now that it is very much unroofed and untethered. Here again, looking and dissecting around the anterior neck of the aneurysm using the very fine ball tip dissector. Here's the final result of the dissection phase, a more magnified view of the anterior neck of aneurysm. Again understanding that small amount of neck has to be left behind to protect the origin of the ophthalmic artery. Again I'm looking for the origin of the ophthalmic artery at this junction. Here, you can see barely the origin of the Ophthalmic artery, distal neck of aneurysm dissecting along the medial part of the neck. Temporal clip was placed. distal to the aneurysm suction-decompression technique was used after a balloon was inflated. Endovascular within the cervical ICA and suction was instituted. You can see the aneurysm is very generously deflated. Now I can see better along the anterior border of the aneurysm. The origin of the Ophthalmic artery is barely visible. Now creating the space for the blades. More aggressively medial to the neck of the aneurysm. After a period of re-perfusion suction-decompression was re-instituted and an angular clip was used to clip like eight the neck of the aneurysm. Here's the initial attempt. Some residual neck may have been apparent there over the aneurysm appears deflated. The plates were advanced. There was some resistance due to the bone across the base of the Intraocular fossa. Here's further advancement of the clip as much as possible. I could not advance the clip plates further because of the bone at the level of the anterior cranial base. Here's the picalm fenestrated clip was also used to close the proximal part of the neck. The nerve appears healthy. Here's a postoperative angiogram, which revealed adequate clip ligation of the aneurysm. Again a portion of the neck had to be left behind to a low patency of the Ophthalmic artery. The postoperative angiogram in this case also demonstrated two very small MCA aneurysms that were clip glycated during a separative operative session. Thank you.

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