Limited Indications for Clipping Surgery of Paraclinoid Aneurysm Based on Long-Term Visual Morbidity

• Published in: World neurosurgery Vol. 134; pp. e153 - e161
• Main Authors: Otani, Naoki, Mori, Kentaro, Wada, Kojiro, Tomiyama, Arata, Toyooka, Terushige, Takeuchi, Satoru, Nakao, Yasuaki, Yamamoto, Takuji, Arai, Hajime
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-02-2020
• Subjects: Adult; Aged; Carotid Artery Diseases - surgery; Cerebral Angiography - adverse effects; Extradural temporopolar approach; Female; Humans; Intracranial Aneurysm - surgery; Male; Microsurgery - methods; Middle Aged; Morbidity; Neurosurgical Procedures - adverse effects; Paraclinoid aneurysm; Surgical Instruments - adverse effects; Time; Treatment Outcome; Visual morbidity; Extradural temporopolar approach; ICA; Paraclinoid aneurysm; BI; ISUIA; EDTPA; ACP; PED; mRS; 3D; CT; MMSE; Visual morbidity
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2019.09.147

Clipping of paraclinoid aneurysm is still challenging because of poor visual morbidity. The extradural temporopolar approach was applied to clip paraclinoid aneurysms, with the expectation of reducing visual morbidity. Factors related to poor visual morbidity were evaluated, to assess the results for clipping of paraclinoid aneurysms.
A series of 40 unruptured paraclinoid aneurysms in 38 patients were clipped via extradural temporopolar approach. Preoperative and postoperative states of visual cognitive function and radiological outcomes were investigated. Aneurysms were classified into dorsal type or non-dorsal type, and small (<9 mm) or not-small (≥9 mm), respectively, to identify factors correlated with visual morbidity.
Complete clipping rate was 90.0% without any recurrence (mean: 5.2 years). Visual morbidity was unexpectedly high at 28.9%, including 2.7% of blindness immediately after the operation, and 23.7% and 2.7% at the final examination (mean: 3.6 years). Multivariate analysis showed aneurysm size was significantly correlated with worse visual outcome. Visual morbidity was 13.3% and 11.1% for dorsal and the non-dorsal small aneurysms, respectively, and all these cases showed visual field defect limited to the nasal quadrant without decreased visual acuity. In contrast, the non-dorsal not-small aneurysms showed significantly worse visual morbidity (60%) with decreased visual acuity.
Clipping via extradural temporopolar approach can achieve durable treatment for small unruptured paraclinoid aneurysms with acceptable visual morbidity. Visual morbidity of the not-small non-dorsal type, however, was poor. The indications for clipping of paraclinoid aneurysm should be limited to small aneurysms, especially the dorsal type in young patients.