Complications of endoscopic third ventriculostomy

2002 ◽  
Vol 96 (6) ◽  
pp. 1032-1040 ◽  
Author(s):  
Henry W. S. Schroeder ◽  
Wulf-Rüdiger Niendorf ◽  
Michael R. Gaab
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Multiorgan Failure ◽  
Cerebrospinal Fluid Leak ◽  
Morbidity Rate ◽  
Third Ventriculostomy ◽  
Oculomotor Palsy ◽  
Effective Treatment Option ◽  
Content Type ◽  
Permanent Morbidity ◽  
Fine Print

Object. The purpose of this prospective investigation was to determine the rate of complications associated with endoscopic third ventriculostomy (ETV). Methods. Between March 1993 and October 2001, 193 ETVs were performed in 188 patients at a single institution. The age of the patients ranged from 1 month to 85 years (mean age 39 years). One procedure had to be abandoned because a severe venous hemorrhage blurred the surgeon's view; however, third ventriculostomy was successfully accomplished in that patient 14 days later. In addition, there were two cases in which significant venous hemorrhages could be controlled endoscopically by using irrigation. Postoperative imaging revealed three subdural collections, one tiny thalamic contusion, one cortical hemorrhage at the puncture site, and one severe subarachnoid hemorrhage (SAH). There were two deaths (1% mortality rate) related to the endoscopic procedure; causes of death were one SAH from a torn basilar perforating artery and one wound infection leading to meningitis and septic multiorgan failure. Three permanent deficits occurred (confusion, oculomotor palsy, and diabetes insipidus [1.6% permanent morbidity rate]). Transient deficits included four cases of meningitis, three cases of cerebrospinal fluid leak, two cases of herniation syndrome, two cases of confusion, one case in which there was a decrease of consciousness, two cases of oculomotor palsy, and one case in which there was loss of thirst (7.8% transient morbidity rate). Misplacement of the fenestration was the main reason for severe complications. During the course of the study, the complication rate dropped significantly (no incidences of mortality or permanent morbidity occurred during the last 100 procedures). Conclusions. All permanent and fatal complications occurred during the authors' very early experience, indicating that a steep learning curve was associated with the procedure. Endoscopic third ventriculostomy, if performed correctly, is a safe, simple, and effective treatment option for various forms of noncommunicating hydrocephalus.

A new device for endoscopic third ventriculostomy

2000 ◽  
Vol 93 (3) ◽  
pp. 509-512 ◽  
Author(s):  
Philippe Decq ◽  
Caroline Le Guerinel ◽  
Stéphane Palfi ◽  
Michel Djindjian ◽  
Yves Kéravel ◽  
...  
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Third Ventricle ◽  
Third Ventriculostomy ◽  
Content Type ◽  
New Device ◽  
The Third ◽  
Endoscopic Control ◽  
Gentle Pressure ◽  
Single Use ◽  
Fine Print

✓ Since its description by Dandy in 1922, several techniques have been used to perform third ventriculostomy under endoscopic control. Except for the blunt technique, in which the endoscope is used by itself to create the opening in the floor of the third ventricle, the other techniques require more than one instrument to perforate the floor of the ventricle and enlarge the ventriculostomy. The new device described is a sterilizable modified forceps that allows both the opening of the floor and the enlargement of the ventriculostomy in a simple and effective way.The new device has the following characteristics: 1) the tip of the forceps is thin enough to allow the easy perforation of the floor of the ventricle; 2) the inner surface of the jaws is smooth to avoid catching vessels of the basal cistern; and 3) the outer surface of the jaws has indentations that catch the edges of the opening to prevent them from slipping along the instrument's jaws. The ventricle floor is opened by gentle pressure of the forceps, which is slowly opened so that the edges of the aperture are caught by the distal outer indentation of the jaws, leading to an approximately 4-mm opening of the floor. This device has been used successfully in 10 consecutive patients.This new device allows surgeons to perform third ventriculostomy under endoscopic control in a very simple, quick, and effective way, avoiding the need for additional single-use instruments.

Endoscopic third ventriculostomy for shunt dysfunction in occlusive hydrocephalus: long-term follow up and review

2003 ◽  
Vol 98 (5) ◽  
pp. 1032-1039 ◽  
Author(s):  
Jürgen Boschert ◽  
Dieter Hellwig ◽  
Joachim K. Krauss
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
The Other ◽  
Third Ventriculostomy ◽  
Content Type ◽  
Shunt Placement ◽  
Occlusive Hydrocephalus ◽  
Shunt Dysfunction ◽  
Fine Print

Object. Endoscopic third ventriculostomy (ETV) is the treatment of choice for occlusive (noncommunicating) hydrocephalus. Nevertheless, its routine use in patients who have previously undergone shunt placement is still not generally accepted. The authors' aim was to investigate the long-term effects of ETV in a group of prospectively chosen patients. Methods. Patients who underwent ETV and had previously undergone shunt placement for occlusive hydrocephalus were followed prospectively for at least 3 years (range 36–103 months, mean 63.6 months). Nine female and eight male patients ranging from 8 to 54 years of age (mean 32 years) had undergone shunt placement 0.7 to 23.5 years (mean 8.1 years) before ETV. Fifteen patients were admitted with underdrainage and two with overdrainage. In six cases, ETV was performed as an emergency operation. The origin of hydrocephalus was aqueductal stenosis in 12 cases and aqueductal compression by a tumor in two cases. Three patients suffered from a fourth ventricle outlet syndrome, and in two patients an additional malresorptive component was suspected. Thirteen patients underwent ETV with shunt removal and insertion of an external drain in one session. The drain served as a safety measure; it could be opened if raised intracranial pressure or ventricular dilation was observed on postoperative imaging studies. In the other four patients the shunt was initially ligated and then removed during a second operation. Fourteen patients (82%) have remained shunt free. The other three patients, including the two with an additional malresorptive component, needed shunt reimplantation 3 days, 2 weeks, or 7 months after ETV. Conclusions. Use of ETV is safe and effective for the treatment for shunt dysfunction in patients with obstructive hydrocephalus.

Fatal subarachnoid hemorrhage after endoscopic third ventriculostomy

1999 ◽  
Vol 90 (1) ◽  
pp. 153-155 ◽  
Author(s):  
Henry W. S. Schroeder ◽  
Rolf W. Warzok ◽  
Jamal A. Assaf ◽  
Michael R. Gaab
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Computerized Tomography ◽  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
Balloon Catheter ◽  
Third Ventriculostomy ◽  
Safe Procedure ◽  
Content Type ◽  
Tomography Scanning ◽  
Fine Print

✓ In recent years, endoscopic third ventriculostomy has become a well-established procedure for the treatment of various forms of noncommunicating hydrocephalus. Endoscopic third ventriculostomy is considered to be an easy and safe procedure. Complications have rarely been reported in the literature. The authors present a case in which the patient suffered a fatal subarachnoid hemorrhage (SAH) after endoscopic third ventriculostomy.This 63-year-old man presented with confusion and drowsiness and was admitted in to the hospital in poor general condition. Computerized tomography scanning revealed an obstructive hydrocephalus caused by a tumor located in the cerebellopontine angle. An endoscopic third ventriculostomy was performed with the aid of a Fogarty balloon catheter. Some hours postoperatively, the patient became comatose. Computerized tomography scanning revealed a severe perimesencephalic—peripontine SAH and progressive hydrocephalus. Despite emergency external ventricular drainage, the patient died a few hours later.Although endoscopic third ventriculostomy is considered to be a simple and safe procedure, one should be aware that severe and sometimes fatal complications may occur. To avoid vascular injury, perforation of the floor of the third ventricle should be performed in the midline, halfway between the infundibular recess and the mammillary bodies, just behind the dorsum sellae.

Use of microvascular Doppler probe to avoid basilar artery injury during endoscopic third ventriculostomy

1999 ◽  
Vol 90 (1) ◽  
pp. 156-159 ◽  
Author(s):  
Richard H. Schmidt
Keyword(s):  
Vascular Injury ◽  
Basilar Artery ◽  
Endoscopic Third Ventriculostomy ◽  
Major Complication ◽  
Safe Zone ◽  
Third Ventriculostomy ◽  
Content Type ◽  
The Third ◽  
Doppler Probe ◽  
Fine Print

✓ Basilar artery (BA) injury has been reported in a number of cases as a major complication of third ventriculostomy for hydrocephalus. This report describes the deployment of a pulsed-wave microvascular Doppler probe through the endoscope to locate the BA complex and subsequently to select a safe zone for perforation of the third ventricular floor. This procedure is quick and easily learned, and it is hoped that it can decrease the risk of vascular injury during third ventriculostomy.

Changes in cerebrospinal fluid hydrodynamics following endoscopic third ventriculostomy for shunt-dependent noncommunicating hydrocephalus

2003 ◽  
Vol 98 (5) ◽  
pp. 1027-1031 ◽  
Author(s):  
Kenichi Nishiyama ◽  
Hiroshi Mori ◽  
Ryuichi Tanaka
Keyword(s):  
Cerebrospinal Fluid ◽  
Absorptive Capacity ◽  
Endoscopic Third Ventriculostomy ◽  
Third Ventriculostomy ◽  
Csf Dynamics ◽  
Shunt System ◽  
Independent State ◽  
Content Type ◽  
Noncommunicating Hydrocephalus ◽  
Fine Print

Object. The aim of this study was to analyze physiological changes in cerebrospinal fluid (CSF) dynamics following endoscopic third ventriculostomy (ETV) for shunt-dependent noncommunicating hydrocephalus. Methods. Clinical data obtained in 15 patients treated with ETV for shunt malfunction were analyzed. Magnetic resonance imaging studies demonstrated the obstruction of the ventricular system preoperatively. After ETV, the existing shunt system was removed and a continuous extraventricular drain, set at 30 cm H2O in height, was installed to measure daily amounts of CSF outflow. Cerebrospinal fluid dynamics after ETV were also evaluated using 111In-diethylenetriamine pentaacetic acid radioisotope cisternography in six of 15 patients within 1 month of the procedure. Three patients underwent cisternography at 6 months after ETV. Cisternograms were obtained at 1, 5, 24, and 48 hours after injection of the radioisotope. To study CSF absorptive capacity, ratios of radioisotope counts at 48 and 5 hours after injection were calculated (C48:C5). Seven of 15 patients had daily outflows of CSF of less than 20 ml; this volume decreased quickly within a few days. The other eight patients demonstrated an outflow of more than 150 ml of CSF for several days, three of whom had signs of transiently increased intracranial pressure. Their CSF outflow volume decreased gradually and symptoms improved within 1 week. Ratios of C48:C5 were within normal limits in five of six patients who had undergone cisternography 1 month after ETV. These ratios were decreased in all three patients who had undergone cisternography at 6 months after ETV compared with that measured at 1 month after the procedure. Conclusions. Our data suggest that CSF dynamics convert from a shunt-dependent state to a shunt-independent state within 1 week following ETV in patients with shunt-dependent noncommunicating hydrocephalus. Nonetheless, intraventricular pressure does not decrease quickly in certain cases. Cerebrospinal fluid absorptive capacity or CSF circulation through the subarachnoid space may show further improvement several months after ETV.

Endoscopic treatment of thalamic neuroepithelial cysts

2005 ◽  
Vol 103 (2) ◽  
pp. 342-346 ◽  
Author(s):  
Kelly Schmidt ◽  
Caetano Coimbra
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Endoscopic Third Ventriculostomy ◽  
Third Ventricle ◽  
Third Ventriculostomy ◽  
Content Type ◽  
The Third ◽  
The Central Nervous System ◽  
Fine Print ◽  
Neuroepithelial Cysts

✓ Thalamic neuroepithelial cysts are rare lesions of the central nervous system. Surgical management of these lesions has varied and yielded mixed results. The authors identified 10 reported cases in the literature, five of which involved symptomatic lesions. The authors present three unique cases of symptomatic thalamic neuroepithelial cysts associated with hydrocephalus, which were all successfully treated using endoscopic third ventriculostomy and fenestration of the cyst into the third ventricle.

Endoscopic third ventriculostomy in the management of obstructive hydrocephalus: an outcome analysis

2004 ◽  
Vol 100 (4) ◽  
pp. 626-633 ◽  
Author(s):  
Hailong Feng ◽  
Guangfu Huang ◽  
Xiaoling Liao ◽  
Kai Fu ◽  
Haibin Tan ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Phase Contrast ◽  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
Aqueductal Stenosis ◽  
Third Ventriculostomy ◽  
Content Type ◽  
Cine Phase Contrast ◽  
Fine Print

Object. The purpose of this paper is to elucidate the safety and efficacy of, and indications and outcome prognosis for endoscopic third ventriculostomy (ETV) in 58 patients with obstructive hydrocephalus. Methods. Between September 1999 and April 2003, 58 ETVs were performed in 58 patients with obstructive hydrocephalus (36 male and 22 female patients) at the authors' institution. The ages of the patients ranged from 5 to 67 years (mean age 35 years) and the follow-up period ranged from 3 to 41 months (mean duration of follow up 24 months). Patients were divided into four subgroups based on the cause of the obstructive hydrocephalus: 21 with intracranial tumors; 11 with intracranial cysts; 18 with aqueductal stenosis; and eight with intracranial hemorrhage or infection. Both univariate and multi-variate statistical analyses were performed to assess the prognostic relevance of the cause of the obstructive hydrocephalus, early postoperative clinical appearance, and neuroimaging findings in predicting the result of the ETV. The survival rate was 87% at the end of the 1st year and 84% at the end of the 2nd year post-ETV. One month after ETV an overall clinical improvement was observed in 45 (77.6%) of 58 patients. If we also consider the successful revision of ETV in two patients, a success rate of 78.3% (47 of 60 patients) was reached. The ETV was successful in 17 (81%) of 21 patients with intracranial tumors, nine (82%) of 11 with cystic lesions, 16 (88.9%) of 18 with aqueductal stenosis, and three (38%) of eight with intracranial hemorrhage or infection. A Kaplan—Meier analysis illustrates that the percentage of functioning ETVs stabilizes between 75 and 80% 1 year after the operation. In a comparison of results 1 year after ETV, the authors found that the aqueductal stenosis subgroup had the highest proportion of functioning ETV (89%). The proportions of the tumor and cyst subgroups were 84 and 82%, respectively, whereas the proportion was only 50% in the ventriculitis/intracranial hemorrhage subgroup (strata log-rank test: χ2 = 7.93, p = 0.0475). In the present study, ETV failed in eight patients (13.8%) and the time to failure after the procedure was a mean of 3.4 months (median 2 months, range 0–8 months). The logistic regression analysis confirmed an early postoperative improvement (within 2 weeks after ETV, significance [Sig] of log likelihood ratio [LLR] < 0.0001) and a patent stoma on cine phase—contrast magnetic resonance (MR) images (Sig of LLR = 0.0002) were significant prognostic factors for a successful ETV. The results demonstrated the multivariate model (B = − 53.7309, standard error = 325.1732, Wald = 0.0273, Sig = 0.8688) could predict a correct result in terms of success or failure from ETV surgery in 89.66% of observed cases. The Pearson chi-square test demonstrated that little reliance could be placed on the finding of a reduced size of the lateral ventricle (χ2 = 5.305, p = 0.07) on neuroimaging studies within 2 weeks after ETV, but it became a significant predictive factor at 3 months (χ2 = 8.992, p = 0.011) and 6 months (χ2 = 10.586, p = 0.005) post-ETV. Major complications occurred in seven patients (12.1%), including intraoperative venous bleeding in three, arterial bleeding in one, and occlusion of the stoma in three patients. The overall mortality rate was 10.3% (six patients). One of these patients died of pulmonary infection and another of ventriculitis. Four additional patients died of progression of malignant tumor during the follow-up period. Conclusions. The results indicate that ETV is a most effective treatment in cases of obstructive hydrocephalus that is caused by aqueductal stenosis and space-occupying lesions. For patients with infections or intraventricular bleeding, ETV has considerable effects in selected cases with confirmed CSF dynamic studies. Early clinical and cine phase—contrast MR imaging findings after the operation play an important role in predicting patient outcomes after ETV. The predictive value of an alteration in ventricle size, especially during the early stage following ETV, is unsatisfactory. Seventy-five percent of ETV failures occur within 6 months after surgery. A repeated ventriculostomy should be considered to be a sufficient treatment option in cases in which stoma dysfunction is suspected.

Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy

2001 ◽  
Vol 95 (5) ◽  
pp. 791-797 ◽  
Author(s):  
Christian Sainte-Rose ◽  
Giuseppe Cinalli ◽  
Franck E. Roux ◽  
Wirginia Maixner ◽  
Paul D. Chumas ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Endoscopic Third Ventriculostomy ◽  
Tumor Resection ◽  
Third Ventriculostomy ◽  
Posterior Fossa Surgery ◽  
Posterior Fossa Tumors ◽  
Content Type ◽  
Group A ◽  
Group B ◽  
Fine Print

Object. The authors undertook a study to evaluate the effectiveness of endoscopic third ventriculostomy in the management of hydrocephalus before and after surgical intervention for posterior fossa tumors in children. Methods. Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at Hôpital Necker—Enfants Malades in Paris. Excluded were 10 patients in whom shunts had been placed at the referring hospital. The medical records and neuroimaging studies of the remaining 196 patients were reviewed and categorized into three groups: Group A, 67 patients with hydrocephalus present on admission in whom endoscopic third ventriculostomy was performed prior to tumor removal; Group B, 82 patients with hydrocephalus who did not undergo preliminary third ventriculostomy but instead received conventional treatment; and Group C, 47 patients in whom no ventricular dilation was present on admission. There were no significant differences between patients in Group A or B with respect to the following variables: age at presentation, evidence of metastatic disease, extent of tumor resection, or follow-up duration. In patients in Group A, however, more severe hydrocephalus was demonstrated (p < 0.01); the patients in Group C were in this respect different from those in the other two groups. Ultimately, there were only four patients (6%) in Group A compared with 22 patients (26.8%) in Group B (p = 0.001) in whom progressive hydrocephalus required treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence reported in the literature and significantly different from that demonstrated in Group A (p < 0.016). The other six patients (7.3%) were treated by endoscopic third ventriculostomy after tumor resection. In Group C, two patients (4.3%) with postoperative hydrocephalus underwent endoscopic third ventriculostomy. In three patients who required placement of CSF shunts several episodes of shunt malfunction occurred that were ultimately managed by endoscopic third ventriculostomy and definitive removal of the shunt. There were no deaths; however, there were four cases of transient morbidity associated with third ventriculostomy. Conclusions. Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. The procedure provides a valid alternative to placement of a permanent shunt in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions. Furthermore, in patients in whom CSF has caused spread of the tumor at presentation, third ventriculostomy allows chemotherapy to be undertaken prior to tumor excision by controlling hydrocephalus. Although the authors acknowledge that the routine application of third ventriculostomy in selected patients results in a proportion of patients undergoing an “unnecessary” procedure, they believe that because patients' postoperative courses are less complicated and because the incidence of morbidity is low and the success rate is high in those patients with severe hydrocephalus that further investigation of this protocol is warranted.

Delayed hemorrhage following resection of an arteriovenous malformation in the brain

2003 ◽  
Vol 99 (6) ◽  
pp. 967-971 ◽  
Author(s):  
Michael K. morgan ◽  
Mark Winder ◽  
Nicholas S. Little ◽  
Simon Finfer ◽  
Elizabeth Ritson
Keyword(s):  
Blood Pressure ◽  
Mortality Rate ◽  
Morbidity Rate ◽  
Content Type ◽  
Delayed Hemorrhage ◽  
Martin Grade ◽  
Permanent Morbidity ◽  
The Brain ◽  
Grade Iii ◽  
Fine Print

Object. Between 1989 and 2002 the authors treated 416 cases of angiographically confirmed arteriovenous malformations (AVMs) of the brain. Methods. Three hundred fifty-five patients underwent resection of an AVM; 2% died and 12% experienced a permanent morbidity (1.7% experienced a deterioration of modified Rankin Scale [mRS] score of 3–5). Patient outcomes in this series were based on the Spetzler—Martin grade. For patients with Grade I and II AVMs the rate of permanent morbidity was 1% and the rate of mortality was 0.5%. For patients with Grade III AVMs the morbidity rate was 18.9% (2.7% experienced a deterioration of mRS score of 3–5) and the mortality rate was 2.7%. For patients with Grade IV and V AVMs the morbidity rate was 25.6% (5.1% experienced a deterioration of mRS score of 3–5) and the mortality rate was 7.7%. No patient with a Spetzler—Martin Grade I or II lesion had a worsened outcome due to delayed hemorrhage, whereas 3.6% of patients with a Grade III and 12.8% of patients with Grade IV and V AVMs experienced delayed hemorrhage that led to a permanent downgrade in function. With the introduction of an aggressive postoperative blood pressure protocol (for AVMs with grades > II and sizes > 3.5 cm in diameter) the incidence of delayed postoperative hemorrhage leading to mortality or permanent morbidity decreased from 4.4 to 1%. This difference was significant. Neither case selection nor complications other than delayed hemorrhage changed between these two periods. Conclusions. In selected cases an aggressive postoperative blood pressure protocol is likely to reduce delayed hemorrhage following AVM resection.

Unruptured paraclinoid aneurysms: a management strategy

2003 ◽  
Vol 99 (2) ◽  
pp. 241-247 ◽  
Author(s):  
Koji Iihara ◽  
Kenichi Murao ◽  
Nobuyuki Sakai ◽  
Atsushi Shindo ◽  
Hideki Sakai ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Management Strategy ◽  
Morbidity Rate ◽  
Content Type ◽  
Group Iii ◽  
Paraclinoid Aneurysms ◽  
Permanent Morbidity ◽  
Group Ii ◽  
Retinal Embolism ◽  
Fine Print

Object. To elucidate an optimal management strategy for unruptured paraclinoid aneurysms, the authors retrospectively reviewed their experience in the treatment of 100 patients who underwent 112 procedures for 111 paraclinoid aneurysms performed using direct surgery and/or endovascular treatment. Methods. Between 1997 and 2002, 111 unruptured paraclinoid aneurysms categorized according to a modified al-Rodhan classification (Group Ia, 30 anterior wall lesions; Group Ib, 25 ventral paraclinoid lesions; Group II, 18 true ophthalmic artery lesions; Group III, 37 carotid cave lesions; and Group IV, one transitional lesion) were treated by direct surgery (35 lesions) and/or endovascular treatment (77 lesions) (one aneurysm was treated by both procedures). In lesions in Groups Ia, Ib, II, and III that were treated by endovascular treatment, complete aneurysm obliteration was achieved in 50, 65, 50, and 78%, respectively, and the combined transient and permanent morbidity rates due to cerebral embolic events were 20, 25, 20, and 13.9%, respectively. Overall, the transient morbidity rate after endovascular treatment was 14.3% and the permanent morbidity rate was 6.5%. Notably, permanent visual deficits caused by retinal embolism occurred after endovascular treatment in two patients with Group II aneurysms. Direct surgery was mainly performed in Groups Ia (20 lesions), Ib (five lesions), and II (eight lesions), with complete neck clip occlusion achieved in 80, 80, and 71.4%, respectively; the transient and permanent morbidity rates associated with aneurysms treated by surgery were 8.6 and 2.9%, respectively. Conclusions. Endovascular therapy for superiorly projecting paraclinoid aneurysms (Groups Ia and II) is associated with lower rates of complete obliteration than direct surgery, and with rates of cerebral embolic events comparable to those of endovascular treatment in the other groups. Furthermore, endovascular treatment for Group II aneurysms entails additional risks of retinal embolism. Therefore, direct surgery is recommended for the treatment of paraclinoid aneurysms projecting superiorly. For other groups, especially for Group III, endovascular treatment is the acceptable first line of therapy.

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