• Right pterional craniotomy for a complex ophthalmic aneurysm

    Case Presentation

    • The patient is a 35 year-old male presenting with fatigue and nausea.
    • CTA showed a 7 mm ICA ophthalmic aneurysm.
    • Patient was impaired with weakness and numbness in the past but has no symptoms at time of surgery.

    Approach

    Pterional craniotomy

    Alternatives

    • Conservative medical management with serial observation
    • Interventional radiology for coiling

    Positioning

    <

    Incision

    • A curvilinear skin incision was made behind the hairline, was chosen for sufficient exposure and cosmetic effect.

    Operation

    • A right pterional craniotomy was performed after reflection of the scalp and temporalis muscle in separate layers.
    • Following the performance of the craniotomy in the usual fashion, dura was opened widely.
    • The operating microscope was then brought into position, and careful dissection down to the internal carotid artery identified ophthalmic artery aneurysm.
    • Intradural bony drilling of the clinoid process was then performed using a 2 mm high-speed cutting and diamond drills to allow for proximal access of the aneurysm neck.
    • Careful dissection isolated the artery of the aneurysm completely as well as the ophthalmic artery.
    • Using temporary occlusion of the internal carotid artery then in the neck allowed for softening the aneurysm, final clip occlusion of the aneurysm using titanium aneurysm clips.
    • Temporary clips were then completely removed. Excellent flow in the proximal and distal normal ICA branches and the ophthalmic artery was confirmed with ICG video angiography and microvascular Doppler as well as complete occlusion of the aneurysm.
    • The wound was copiously irrigated.
    • Hemostasis was excellent.
    • The dura was loosely approximated.
    • It was covered with synthetic dural graft.
    • The bone was replaced using titanium plates and screws, and the scalp and neck incisions were closed using interrupted sutures and staples.
    • There were no complications.

    Post Op

    • Complication of double vision binocularly on POD1 with immediate improvement with steroids. CT head showed normal post-op changes.
    • Discharged home on POD2.

    Outcome

    • Patient is doing well and has no neurological symptoms at 6 week follow-up.
    • CT 1.5 years post-op showed focal 2.3 mm outpouching along the medial aspect of the supraclinoid portion of the right internal carotid along the inferior margin of the aneurysm clip.

    Pearls and Pitfalls

    • Surgical treatment of ophthalmic aneurysms requires precise anatomical knowledge of the relationship of the anterior clinoid to the carotid artery and optic nerve.
    • Excellent results can be achieved with microsurgical clipping of ophthalmic artery aneurysms.

    Discussion

    • The dural incisions for intradural anterior clinoid process removal.1
    • The dashed lines along the medial sphenoid wing and anterior clinoid remnant represent the dural incision.1
    • An extension of this incision is carried through the falciform ligament and lateral optic nerve ensheathment to decompress and mobilize the optic nerve.1
    • Exposure following intradural anterior clinoid process removal and optic strut drilling.1
    • The dashed line represents the dural incision along the subarachnoid space surrounding the optic nerve within the optic canal.1
    • The optic nerve is then markedly decompressed and mobile; a stitch is placed at the intracranial end of the opening of the optic canal dura, and retracted in the direction of the arrow to allow a completely open view of the dural ring and the ophthalmic artery origin.1

    References

    • Spetzler, RF. Kalani, MYS. Nakaji P. (2015). Neurovascular Surgery. ed. New York, NY: Thieme Medical Publishers, Inc.
    • Bambakidis, NC. Nakaji, P. Amin-Hanjani, S. Spetzler, RF. (2015). Cerebrovascular surgery: an interactive video atlas. ed. Shelton, CT: PMPH-USA.

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