Eight cases of ventral (paraclinoid) internal carotid artery aneurysms are presented. These aneurysms often challenge the surgeon because (a) they are partially or completely obscured by the optic nerve, internal carotid artery, and anterior clinoid process; (b) there is no proximal internal carotid artery control intracranially; and (c) part of the neck and fundus of the aneurysm is located within the cavernous sinus. These aneurysms, which have been classified as separate from the typical carotid-ophthalmic aneurysm group, are illustrated, and their surgical treatment and problems described.
"It should be noted that the blood supply to the optic nerve or chiasm may also be compromised by occlusion or distortion of the ophthalmic artery or small branches of the ICA in the parasellar/suprasellar region. Moreover, Fox  suspected that retinal ischemia associated with temporary occlusion of proximal arteries was one cause of postoperative deterioration of visual function. Date et al  reported that the most important factor for prediction of outcome on visual function after the treatment of paraclinoid aneurysm was the interval between the onset of visual symptoms and surgery rather than the type of surgical method. "
[Show abstract][Hide abstract] ABSTRACT: Clipping a paraclinoid aneurysm is difficult if the patient has a visual disturbance. Visual function sometimes deteriorates postoperatively for patients with a large aneurysm. In this study, we report the long-term follow-up of patients with visual impairments attributed to optic nerve compression when paraclinoid aneurysms are surgically treated.
Seventeen patients with optic nerve impairment induced by compression of paraclinoid ICA aneurysms were treated. All of the aneurysms were large, including 6 giant aneurysms. The aneurysms displayed partial thrombosis or calcification of the aneurysmal wall in 6 cases.
Direct surgery such as neck clipping or wrapping of the aneurysm was performed in 9 aneurysms and indirect procedures in 8 others (ICA occlusion, 1; ICA occlusion + bypass, 7). Of 17 patients, 11 (65%) showed improvement in several dysfunctions of visual acuity or visual field. Of 6 patients, whose vision had not recovered well, 5 underwent direct surgery. Moreover, these 5 patients had an intra-aneurysmal thrombosis or calcification of the aneurysmal wall. Nevertheless, 1 patient whose aneurysm with partial thrombosis was treated via indirect procedure had good recovery of vision.
Direct clipping is the treatment of choice for patients with a mass effect on the optic nerve due to paraclinoid aneurysm. However, it is difficult to achieve sufficient decompression of the optic nerve when the aneurysm is accompanied by partial thrombosis or calcification of the aneurysmal wall. In those cases, an indirect procedure seems to be a relatively safe, effective treatment.
[Show abstract][Hide abstract] ABSTRACT: The anterior cavernous sinus space is the venous space anterior to the cavernous carotid artery. It is tetrahedral in shape with the anterior apex at the superior orbital fissure. The superomedial wall is formed by the base of the anterior clinoid process. The inferomedial wall is formed by the sphenoid bone. The lateral wall consists of two layers of dura with the oculomotor, trochlear, ophthalmic and abducens nerves in the inner layer. Medially, the posterior wall consists of the cavernous carotid artery. Laterally, it communicates with the lateral cavernous sinus space. Paraclinoid and carotid cave aneurysms may occupy this space and its microanatomy is important in the surgery of these aneurysms.
[Show abstract][Hide abstract] ABSTRACT: A method is described in which we use a combined endovascular balloon-catheter technique and open microneurosurgical approach for clipping aneurysms of the proximal paraclinoidal intracranial segment of the internal carotid artery. By temporary occlusion of the cervical carotid artery and continuously retrograde sucking of blood from the distal vessel via a double-lumen balloon-catheter, clip application to large and critically located aneurysms is facilitated applying evacuation-decompression to the trapped arterial segment under intra-operative SEP-monitoring.
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