Temporary Clipping of the Intracavernous Internal Carotid Artery: A Novel Technique for Proximal Control

Abstract BACKGROUND Securing proximal control in complex paraclinoid aneurysm surgery through traditional techniques may be challenging and risky in certain situations. Advancements of anatomical knowledge of the cavernous sinus (CS) and hemostasis have made it more accessible as a surgical option. OBJECTIVE To describe the technique of temporary clipping of the horizontal segment of the intracavernous internal carotid artery (IC-ICA) in preparation for permanent clipping of complex paraclinoid aneurysms. METHODS Through an extradural pretemporal approach, the lateral wall of the CS is exposed. The dura between the trochlear nerve and V1 is opened, and access is made to the horizontal segment of the IC-ICA. After circumferential dissection, the temporary clip can be introduced to the artery, and the extradural clinoidectomy can be continued under secured proximal control. RESULTS Seven patients with complex paraclinoid aneurysms were treated between May 2013 and May 2016 by the senior author. Temporary clipping of the IC-ICA was performed in all cases. Average time to achieve proximal control was 22.6 min (22.6 ± 13.8). One patient developed transient oculomotor palsy postoperatively. There were no other complications. CONCLUSION When the exposed clinoidal segment of the internal carotid artery does not offer sufficient proximal space for temporary clipping, the extradural approach can be extended to the horizontal portion of the IC-ICA. In our experience, this technique is a quick, reliable, and safe alternative to the classical modalities of temporary occlusion.

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How I do it: proximal control in parkinson’s triangle for a very large paraclinoid aneurysm

Acta Neurochirurgica ◽

10.1007/s00701-021-04961-6 ◽

2021 ◽

Author(s):

Victor Volovici ◽

Ruben Dammers

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Viable Alternative ◽

Partial Removal ◽

Safe Alternative ◽

Anterior Clinoid Process ◽

Working Space ◽

Paraclinoid Aneurysm ◽

Paraclinoid Aneurysms

Abstract Background Paraclinoid aneurysms, especially when they are large, can be quite difficult to treat, both endovascularly and through microsurgical clip reconstruction. There are many possibilities to approach this region surgically, and most hinge on total or partial removal of the anterior clinoid process. Gaining proximal control may be a challenge when space is limited, which is why Parkinson’s triangle may be a viable alternative in some cases. Methods We describe in a stepwise fashion the steps used to reconstruct a very large paraclinoid aneurysm. We first attempted to gain proximal control in the carotid cave and later in Parkinson’s triangle because of limited manoeuvrability. Conclusion Proximal control in Parkinson’s triangle can be a safe alternative when the post-clinoidal segment of the internal carotid artery (ICA) is short and working space is limited in paraclinoid aneurysm microsurgical clip reconstruction.

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Endovascular Treatment for Lateral Wall Paraclinoid Aneurysms and the Influence of Internal Carotid Artery Angle

Neurologia medico-chirurgica ◽

10.2176/nmc.oa.2020-0307 ◽

2021 ◽

Vol 61 (4) ◽

pp. 275-283

Author(s):

Natsuki SUGIYAMA ◽

Takashi FUJII ◽

Kenji YATOMI ◽

Kosuke TERANISHI ◽

Hidenori OISHI ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Endovascular Treatment ◽

Internal Carotid ◽

Lateral Wall ◽

Paraclinoid Aneurysms

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Microsurgical Anatomy and Surgical Exposure of the Petrous Segment of the Internal Carotid Artery

Operative Neurosurgery ◽

10.1227/01.neu.0000327037.75571.10 ◽

2008 ◽

Vol 63 (suppl_4) ◽

pp. ONS210-ONS239 ◽

Cited By ~ 14

Author(s):

Shigeyuki Osawa ◽

Albert L. Rhoton ◽

Necmettin Tanriover ◽

Satoru Shimizu ◽

Kiyotaka Fujii

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Sphenoid Sinus ◽

Internal Carotid ◽

Lateral Wall ◽

Common Trunk ◽

Microsurgical Anatomy ◽

Carotid Canal ◽

Complex Relationships ◽

Arteries And Veins

Abstract Objective: The petrous segment of the internal carotid artery has been exposed in the transpetrosal, subtemporal, infratemporal, transnasal, transmaxillary, transfacial, and a variety of transcranial approaches. The objective of the current study was to examine anatomic features of the petrous carotid and its branches as related to the variety of approaches currently being used for its exposure. Methods: Twenty middle fossae from adult cadaveric specimens were examined using magnification of ×3 to ×40 after injection of the arteries and veins with colored silicone. Results: The petrous carotid extends from the entrance into the carotid canal of the petrous part of the temporal bone to its termination at the level of the petrolingual ligament laterally and the lateral wall of the sphenoid sinus medially. The petrous carotid from caudal to rostral was divided into 5 segments: posterior vertical, posterior genu, horizontal, anterior genu, and anterior vertical. Fourteen (70%) of the 20 petrous carotids had branches. The branch that arose from the petrous carotid was either a vidian or periosteal artery or a common trunk that gave rise to both a vidian and 1 or more periosteal arteries. The most frequent branch was a periosteal artery. Conclusion: An understanding of the complex relationships of the petrous carotid provides the basis for surgically accessing any 1 or more of its 5 segments.

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Carotid paraclinoid aneurysms with intradural origin and intracavernous location

Journal of Neurosurgery ◽

10.3171/jns.1978.48.4.0526 ◽

1978 ◽

Vol 48 (4) ◽

pp. 526-533 ◽

Cited By ~ 90

Author(s):

Stephen Nutik

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Precise Definition ◽

Separate Entity ◽

Content Type ◽

Paraclinoid Aneurysms ◽

Planning Treatment ◽

Definition Of ◽

Fine Print

✓ Five cases of a congenital berry aneurysm of the internal carotid artery with origin partially intradural and fundus mainly intracavernous are presented. Angiography does not allow a precise definition of the amount of aneurysm that is intradural, a fact of importance when planning treatment of these cases. However, the angiographic features are characteristic of the type and suggest that these aneurysms be grouped together as a separate entity.

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Meningovenous Structures of the Petroclival Region: Clinical Importance for Surgery and Intravascular Surgery

Neurosurgery ◽

10.1097/00006123-200204000-00027 ◽

2002 ◽

Vol 50 (4) ◽

pp. 829-837 ◽

Cited By ~ 44

Author(s):

Mehmet Faik Ozveren ◽

Koichi Uchida ◽

Sadakazu Aiso ◽

Takeshi Kawase

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Nerve Injury ◽

Internal Carotid ◽

Abducens Nerve ◽

Lateral Wall ◽

Petrous Apex ◽

Anatomic Variations ◽

Arachnoid Membrane ◽

Petroclival Region

Abstract OBJECTIVE: The goals of this investigation were to perform a detailed analysis of petroclival microanatomic features, to investigate the course of the abducens nerve in the petroclival region, and to identify potential causes of injury to neurovascular structures when anterior transpetrosal or transvenous endovascular approaches are used to treat pathological lesions in the petroclival region. METHODS: Petroclival microanatomic features were studied bilaterally in seven cadaveric head specimens, which were injected with colored silicone before microdissection. Another cadaveric head was used for histological section analyses. RESULTS: A lateral or medial location of the abducens nerve dural entrance porus, relative to the midline, was correlated with the course and angulation of the abducens nerve in the petroclival region. The angulation of the abducens nerve was greater and the nerve was closer to the petrous ridge in the lateral type, compared with the medial type. The abducens nerve exhibited three changes in direction, which represented the angulations in the petroclival region, at the dural entrance porus, the petrous apex, and the lateral wall of the internal carotid artery. The abducens nerve was covered by the dural sleeve and the arachnoid membrane, which became attenuated between the second and third angulation points. The abducens nerve was anastomosed with the sympathetic plexus and fixed by connective tissue extensions to the lateral wall of the internal carotid artery and the medial wall of Meckel's cave at the third angulation point. There were two types of trabeculations inside the sinuses around the petroclival region (tough and delicate). CONCLUSION: The petroclival part of the abducens nerve was protected in a dural sleeve accompanied by the arachnoid membrane. Therefore, the risk of abducens nerve injury during petrous apex resection via the anterior transpetrosal approach, with the use of the transvenous route through the inferior petrosal sinus to the cavernous sinus, should be lower than expected. The presence of two anatomic variations in the course of the abducens nerve, in addition to findings regarding nerve angulation and tethering points, may explain the relationships between adjacent structures and the susceptibility to nerve injury with either surgical or endovascular approaches. Venous anatomic variations may account for previously reported cases of subarachnoid hemorrhage with the endovascular approach.

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Relationship between the ophthalmic artery and the dural ring of the internal carotid artery

Journal of Neurosurgery ◽

10.3171/2008.11.jns08766 ◽

2009 ◽

Vol 111 (1) ◽

pp. 119-123 ◽

Cited By ~ 21

Author(s):

Tetsuyoshi Horiuchi ◽

Yuichiro Tanaka ◽

Yoshikazu Kusano ◽

Takehiro Yako ◽

Tetsuo Sasaki ◽

...

Keyword(s):

Surgical Treatment ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Ophthalmic Artery ◽

Internal Carotid ◽

Medial Side ◽

Paraclinoid Aneurysm ◽

Paraclinoid Aneurysms ◽

Ophthalmic Arteries

Object The ophthalmic artery (OphA) usually arises from the intradural internal carotid artery (ICA), and the extradural origin has also been known. However, the interdural origin is extremely rare. The purpose of this paper was to clarify the origin of the OphA in patients with a paraclinoid aneurysm in the ICA based on intraoperative findings. Methods The authors retrospectively examined 156 patients who underwent direct surgical treatment for 166 paraclinoid aneurysms during a 17-year period. Based on intraoperative findings, 119 ophthalmic arteries were analyzed with respect to their origins. Results The OphA originated from the intradural ICA on 102 sides (85.7%), extradural on 9 (7.6%), and interdural on 8 (6.7%). Although the extradural origin might be recognized preoperatively, it was difficult to distinguish the interdural origin of the OphA from the intradural one. Conclusions The incidence of the interdural origin was 6.7% and was not as rare as the authors expected. Neurosurgeons should know the possible existence of the interdural origin of the OphA to section the medial side of the dural ring.

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Case of step-by-step combined treatment of a patient with a ruptured aneurysm of the ophthalmic segment of the internal carotid artery

Sechenov Medical Journal ◽

10.47093/2218-7332.2021.277.02 ◽

2021 ◽

Author(s):

D. V. Litvinenko ◽

E. I. Zyablova ◽

V. V. Tkachev ◽

G. G. Muzlaev

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Surgical Intervention ◽

Combined Treatment ◽

Cerebral Aneurysms ◽

Treatment Method ◽

Endovascular Coiling ◽

Paraclinoid Aneurysms ◽

Angiographic Examination

Aneurysms of the internal carotid artery are the second most common among cerebral aneurysms. When an aneurysm is located in the ophthalmic segment of the internal carotid artery (ICA), the intravascular treatment method is a priority. At the same time, the treatment of recurrent and non-radially switched-off aneurysms of this localization remains a subject of discussion.Case report. We present a 42-year-old patient with a ruptured ICA aneurysm who was admitted in a serious condition. Initially, the patient underwent partial occlusion of the aneurysm cavity with endovascular coiling. In the control cerebral angiography 3 months after the haemorrhage, the recanalization of the aneurysm was verified, which served as an indication for repeated surgical intervention. We preferred the microsurgical method of treatment. A control angiographic study 1 year after the second operation confirmed the radical shutdown of the aneurysm.Discussion. The presented case illustrates the need for a flexible approach in the treatment of complex paraclinoid aneurysms. The choice of endovascular treatment of such aneurysms in the acute period of haemorrhage is justified as the most sparing, although less radical. Depending on the nature of the embolization performed, the timing of the control angiographic examination should be selected individually and can be reduced to 2 months. If there are indications for repeated surgical intervention, it should be performed by the safest method, providing total shutdown of the aneurysm and reducing the volumetric impact of the aneurysm dome on the optic nerve.

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