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Papers of the Week

2022 Apr 08

World Neurosurg

Role of Extradural Clinoidectomy and Trapping in Giant Superior Hypophyseal Artery Aneurysm.


Das K K, Kumar R, Verma P K, Pattankar S, Singh G, Singh V, Kumar Srivastava A
World Neurosurg. 2022 Apr 08.
PMID: 35405316.


Giant paraclinoid internal carotid artery (ICA) aneurysms are surgically challenging, mainly due to the lack of adequate working space and distortion of the regional anatomy. Anterior clinoidectomy is a vital surgical technique in such cases, allowing optic nerve decompression, and exposure of the proximal ICA outside the arachnoid confines. While this is generally conducted intradurally, some aneurysms, particularly unruptured and directed medially paraclinoid ICA aneurysms can allow a completely extradural clinoidectomy. The latter avoids bone dust spillage and accidental drill bit related injury from prolonged intradural drilling times. An 18-year-old boy with a giant left superior hypophyseal artery aneurysm presented with progressive headache and visual diminution. He had a very good cross-flow from the contralateral ICA and tolerated the balloon test occlusion (BTO). Following the extradural clinoidectomy and optic nerve mobilisation, the aneurysm was exposed. It was a wide-necked aneurysm and involved the distal dural ring. Bolstered by intraoperative somatosensory evoked potential findings as well as our concern of inadequate neck occlusion in view of the distal dural ring involvement and a possible future aneurysm regrowth, we trapped the aneurysm. The patient made an uneventful recovery with improvement in vision and normal visual fields. This video demonstrates the feasibility and utility of extradural clinoidectomy in adequate exposure of giant paraclinoid aneurysms and the role of aneurysm trapping for definitive aneurysm obliteration when the distal dural ring is involved. Trapping, as against a direct clipping, avoids manipulation of the compressed optic nerves, necessary for an optimal environment for postoperative visual recovery.