Unruptured paraclinoid aneurysms: a management strategy

Koji Iihara Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Kenichi Murao Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Nobuyuki Sakai Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Atsushi Shindo Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Hideki Sakai Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Toshio Higashi Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Shuji Kogure Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Jun C. Takahashi Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Katsuhiko Hayashi Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Toshihiro Ishibashi Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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Izumi Nagata Department of Cerebrovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

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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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