Microsurgical treatment of carotid-ophthalmic aneurysm associated with multiple anterior and posterior circulation aneurysms: A case report

Abstract

Background
The clipping of multiple intracranial aneurysms in 1 stage is uncommon. In this case, we report clipping of an ophthalmic aneurysm associated with multiple anterior and posterior circulation aneurysms via the Dolenc approach.

Methods
The main symptoms of the patient are headache, along with nausea and vomiting. The patient's arteriogram revealed a wide-necked aneurysm of the right ophthalmic artery, an irregular aneurysm of the anterior communicating artery, and a basilar artery aneurysm. The surgical intervention for these aneurysms is a challenge because of the complex anatomical relationship with the surrounding structures. The 3 aneurysms, which were not amenable to a single intervention, were successfully clipped in 1 incision.

Results
After surgery, the patient reported feeling well. One year after surgery, the patient had no SAH recurrence.

Conclusions
Occasionally, surgical treatment was used even for aneurysms of the carotid-ophthalmic artery with aneurysms of anterior communicating artery and basilar artery, which are contraindicated for interventional therapy.

Full text

Microsurgical treatment of carotid-ophthalmic
aneurysm associated with multiple anterior and
posterior circulation aneurysms
A case report
Jiantao Wang, MD
a,b
, Zhisheng Kan, MD
b
, Shuo Wang, MD
a,∗
Abstract
Background: The clipping of multiple intracranial aneurysms in 1 stage is uncommon. In this case, we report clipping of an
ophthalmic aneurysm associated with multiple anterior and posterior circulation aneurysms via the Dolenc approach.
Methods: The main symptoms of the patient are headache, along with nausea and vomiting. The patient’s arteriogram revealed a
wide-necked aneurysm of the right ophthalmic artery, an irregular aneurysm of the anterior communicating artery, and a basilar artery
aneurysm. The surgical intervention for these aneurysms is a challenge because of the complex anatomical relationship with the
surrounding structures. The 3 aneurysms, which were not amenable to a single intervention, were successfully clipped in 1 incision.
Results: After surgery, the patient reported feeling well. One year after surgery, the patient had no SAH recurrence.
Conclusions: Occasionally, surgical treatment was used even for aneurysms of the carotid-ophthalmic artery with aneurysms of
anterior communicating artery and basilar artery, which are contraindicated for interventional therapy.
Abbreviations: ACP =anterior clinoid process, DSA =digital subtraction angiography, ICA =internal carotid artery.
Keywords: carotid-ophthalmic artery aneurysm, classification, clipping, multiple
1. Introduction
Ophthalmic internal carotid artery (ICA) aneurysms are a
challenging subset of intracranial aneurysms. The ophthalmic
(C6) segment extends from the distal dural ring to the origin of
the posterior communicating artery.
[1]
The segment is known as
the carotid-ophthalmic segment
[2]
and the paraclinoid segment.
[3]
Internal carotid artery (ICA)-ophthalmic artery aneurysms
constitute 0.3% to 1% of intracranial aneurysms and 0.9% to
6.5% of aneurysms of the ICA.
[4]
They represent a surgical
challenge because of the anatomical complexity of the para-
clinoid region, and proximity to the optic apparatus, as well as
partial intracavernous extension in a few patients.
[5]
We report
the surgical clipping of carotid-ophthalmic aneurysm in patients
with multiple anterior and posterior circulation aneurysms
intracranially.
2. Case report
A 47-year-old woman with unremarkable medical history
presented with sudden headache, along with nausea and
vomiting. Physical examination revealed a stiff neck. Visual
acuity and field were within normal limits, with Hunt & Hess
grade II.
The CT scan showed subarachnoid hemorrhage (Fig. 1).
Digital subtraction angiography (DSA) with 3-dimensional
reconstruction revealed a 6-mm wide-necked aneurysm of the
right ophthalmic artery projecting superomedially, a 8-mm
saccular aneurysm on the top of basilar artery and an irregular
5-mm aneurysm of anterior communicating artery projecting
anterosuperiorly, which caused the hemorrhage (Fig. 2). The
aneurysms were successfully obliterated with microsurgical
clipping using a single craniotomy. Postoperative computed
tomographic angiography (CTA) demonstrated complete disap-
pearance of all the aneurysms (Fig. 3), and the patient was
discharged after 14 days without any neurological deficits. The
patient is alive and healthy without any neurological deficits, 1
year after surgery.
The case is unique in that the 3 aneurysms were successfully
clipped in 1 incision using extended pterional craniotomy with a
temporal extension, to expose the cervical carotid arteries
initially. After the craniotomy flap was established, the sphenoid
wing was drilled laterally to its medial extension until the anterior
clinoid process was reached. The anterior clinoid process was
exposed and removed extradurally. During exposure and surgical
clipping of the aneurysm, a sharp dissection was used to open the
arachnoid of the lamina terminalis cistern and the arachnoid
between the optic nerves and gyrus rectus. A straight clip was
applied across the neck of the anterior communicating artery
aneurysm (Fig. 4A and B). The microtechnique was continued by
extending the dissection laterally to the right internal carotid
Editor: Bernhard Schaller.
Ethical approval: This study was approved by our hospitals. Informed consent
was obtained from all individual participants included in the study.
The authors have no funding and conflicts of interest to disclose.
a
Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical
University, Beijing, China,
b
Department of Neurosurgery, Beijing Anzhen Hospital,
Capital Medical University, Beijing, China.
∗
Correspondence: Shuo Wang, Beijing Tiantan Hospital, Capital Medical
University, Beijing, China
(e-mails: captain9858@vip.sina.com; 13651263232@163.com).
Copyright ©2017 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Medicine (2017) 96:16(e6672)
Received: 27 October 2016 / Received in final form: 17 March 2017 / Accepted:
20 March 2017
http://dx.doi.org/10.1097/MD.0000000000006672
Clinical Case Report Medicine®
OPEN
1

artery. The paraclinoidal aneurysm was dissected and clearly
visualized (Fig. 4C). The aneurysm originating in the dorsal
surface of the C6 segment and was close to the ophthalmic artery
origin. The subtype Ia
[6]
was close to the ophthalmic artery
origin, and a straight aneurysm clip was applied across the neck
of the aneurysm (Fig. 4D). Along the direction of the posterior
cerebral artery, the basilar trunk was directly exposed in the
interpeduncular cistern. A saccular aneurysm with a wide and
dysmorphic base was detected at the top of the basilar artery.
Afterblocking the temporary proximal aneurysm, the size of
the aneurysm was reduced using low-power electrocautery
(Fig. 4E–G). A straight aneurysm clip replaced the temporary
clip across the neck of the aneurysm (Fig. 4H).
3. Discussion
We report a patient with multiple aneurysms located in the
carotid-ophthalmic artery, the anterior communicating artery
and the basilar artery. We used a single craniotomy to
successfully clip all the aneurysms, which were refractory to
single intervention.
Based on DSA information, ophthalmic segment aneurysms
are classified into 4 groups as reported by Barami et al.
[6]
Types Ia
and Ib originate on the dorsal surface of C6. Type Ia is related to
the ophthalmic artery. Type Ib aneurysms are sessile, without any
branch points. From a surgical perspective, the type I aneurysms
are easiest to treat, with limited correlation with superior
hypophysial vessels or other strategically important vessels.
Frequently, only the optic nerve and the OphA artery must be
negotiated. Surgery is the first-line therapy for paraclinoid
aneurysms (Type I), unless the neck of the aneurysm is heavily
calcified or contraindications exist.
[7]
The ophthalmic segment
aneurysm is classified under the type I category.
Paraclinoid aneurysms represent one of the most appropri-
ate targets for endovascular intervention. However, endo-
vascular treatment has a lower success rate for total
occlusion.
[8,9]
In addition, it is associated with recurrence,
especially, of lesions incompletely occluded initially.
[10,11]
Microsurgery remains the primary treatment for ICA
aneurysms of the paraclinoid segment, resulting in a higher
rate of long-term success.
[11]
Occasionally, the combination of
surgical and endovascular approaches is an effective strate-
gy.
[12]
Anticoagulation after intervention leads to ruptured
aneurysm, and patients with multiple aneurysms may be
contraindicated for interventional therapy. In our patient with
ophthalmic segment aneurysm, young age and good health
aneurysm location and the wide neck of the other aneurysms
are indications for surgical clipping.
The contraindications for interventional therapy of aneurysms
are discussed below.
1. The type 1 or superior projecting paraclinoid aneurysms
showing instability of the microcatheter are inappropriate for
intervention. By contrast, aneurysms projecting inferiorly
(ventral paraclinoid aneurysms), in which the location of
aneurysms within the concavity of the curve formed by the
carotid siphon facilitate catheterization.
[7]
2. Anticoagulation leads to rupture in patients with multiple
aneurysms.
3. Other factors, such as aneurysm shape and neck size, as well as
the wishes of patient’s family affect the treatment. Wide-
necked basilar artery aneurysms are difficult to treat using
endovascular therapy. Therefore, a temporary blockage of
proximal aneurysm was used to reduce the size using low-
power electrocautery followed by straight clipping across the
neck of the aneurysm.
The optimal therapy for multiple intracranial aneurysms
remains unclear. Elective surgery is recommended for unrup-
tured intracranial aneurysms. The risk of rupture was high in
our patient with SAH. When surgery is indicated for ruptured
aneurysm, the additional effort to clip the other unruptured
aneurysms is minimal, obviating the need for a second
craniotomy. Although surgical indications for ophthalmic
segment aneurysms are minimized with the success of
endovascular techniques, multiple aneurysms are still a
challenge due to their different locations. However, long-term
follow-up data show higher rates of recurrence and re-
treatment with endovascular intervention, and surgical clipping
continues to be strongly preferred.
[13]
Although multiple
aneurysms are difficult to treat with surgical clamping, the
use of appropriate surgical methods, adequate exposure, and
clipping facilitate successful management. We used the
extradural approach adopted by Dolenc
[14]
for paraclinoid
aneurysms and basilar tip,
[15]
to treat the aneurysms of the
anterior communicating artery, the basilar artery, and the
paraclinoid segment.
The anterior clinoid process (ACP) interferes with clipping. It
is necessary to remove the ACP followed by optic canal
unroofing to expose the ophthalmic segment aneurysm. The
ACP resection can be performed intradurally or extradurally.
The proponents of extradural clinoidectomy maintain that the
dural layer protects the brain and cortical vessels during the
drilling, and prevents bone dust and bleeding into the
Figure 1. CT demonstrating subarachnoid hemorrhage. CT =computed tomography.
Wang et al. Medicine (2017) 96:16 Medicine
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subarachnoid space.
[1]
By contrast, intradural clinoidectomy
provides a clear view of the ACP, ICA, and optic nerve, which
are protected during clinoidectomy. We treated our case with
extradural clinoidectomy.
Our experience suggests that surgical treatment is superior to
endovascular treatment. Surgical clipping releases optic nerve
compression and completely occludes the aneurysm neck. It
provides durable repair, without the need for antiplatelet agents
in the setting of acute aneurysm rupture.
As a cost-effective, noninvasive modality, CTA is a promising
alternative to DSA fo r initial and long-term evaluat ion of residual
cerebral aneurysms (RA), although DSA remains the gold
standard.
[16]
Therefore, we used CTA as a means of postopera-
tive assessment of RA .By implementing multidetector CTA
Figure 3. Postoperative CTA showing clipped aneurysms. CTA =computed tomographic angiography.
Figure 2. (A, D) Right carotid angiography demonstrated a carotid-ophthalmic artery aneurysm with upper projection. (B, E) Left vertebral angiography
demonstrated a basilar artery aneurysm. (C, F)Left carotid angiography demonstrated an anterior communicating artery aneurysm.
Wang et al. Medicine (2017) 96:16 www.md-journal.com
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technology in experienced centers, the sensitivity and specificity
of CTA may approach that of traditional DSA for detecting
RA.
[16]
4. Conclusion
Single craniotomy was successfully used to clip ophthalmic
segment aneurysms associated with other aneurysms. Despite a
narrow range of indications for endovascular interventions in
patients with ophthalmic segment aneurysms, management of
multiple aneurysms is still a challenge due to their different
locations. The successful outcome reported here defines the
feasibility but not the efficacy of endovascular approach. The
procedure requires extreme prudence along with adequate
experience and skills when used as a possible alternative to
other well-established techniques.
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Figure 4. Intraoperative view of (A) anterior communicating artery aneurysm (ACOA); (B) clip across the ACOA neck; (C) ophthalmic artery aneurysm (OAA); (D) clip
across the OAA neck; (E) blocking of temporary proximal basilar aneurysm (BA); (F) BA; (G) BA size was reduced using low-power electrocautery; (H) clip across the
BA neck. ACOA =anterior communicating artery aneurysm, BA =basilar aneurysm, OAA =ophthalmic artery aneurysm.
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