Direct microsurgical repair of intracavernous vascular lesions

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✓ Three patients with aneurysms of the internal carotid artery (ICA) situated in the cavernous sinus (CS), and four patients with traumatic carotid-cavernous fistulas (CCF's) were treated by direct surgical approach. Two aneurysms were clipped, whereas the third (a giant aneurysm) was resected and the wall of the ICA reconstructed using interrupted sutures. In two CCF's, the shunt was excluded during reconstruction of the ICA wall by suturing. In the remaining two patients with CCF's, the shunt was excluded by clipping. The CS was attacked directly using a combination of three different techniques: the pterional, the subtemporal, and the petrosal approach. The ICA in its whole course through the CS, as well as the third through the sixth cranial nerves, were exposed. No special measures, such as hypotension, hypothermia, extracorporeal circulation and cardiac arrest, or dehydration, were taken during surgery. The aim of the direct approach to the CS was to exclude the aneurysm and/or the CCF and preserve the ICA patency. In all seven cases operated on, the lesions were excluded without inflicting any additional damage to the third through sixth cranial nerves, and in five cases carotid patency was preserved.

Abstract

✓ Three patients with aneurysms of the internal carotid artery (ICA) situated in the cavernous sinus (CS), and four patients with traumatic carotid-cavernous fistulas (CCF's) were treated by direct surgical approach. Two aneurysms were clipped, whereas the third (a giant aneurysm) was resected and the wall of the ICA reconstructed using interrupted sutures. In two CCF's, the shunt was excluded during reconstruction of the ICA wall by suturing. In the remaining two patients with CCF's, the shunt was excluded by clipping. The CS was attacked directly using a combination of three different techniques: the pterional, the subtemporal, and the petrosal approach. The ICA in its whole course through the CS, as well as the third through the sixth cranial nerves, were exposed. No special measures, such as hypotension, hypothermia, extracorporeal circulation and cardiac arrest, or dehydration, were taken during surgery. The aim of the direct approach to the CS was to exclude the aneurysm and/or the CCF and preserve the ICA patency. In all seven cases operated on, the lesions were excluded without inflicting any additional damage to the third through sixth cranial nerves, and in five cases carotid patency was preserved.

The location of the cavernous sinus (CS), its architecture, and the relationship between the structures running through the sinus are generally known. Recent meticulous microsurgical studies of the CS have disclosed in detail the topographic anatomy of the internal carotid artery (ICA) and the third, fourth, fifth, and sixth cranial nerves as they course through the CS.10,16,17,26 Although intracavernous carotid aneurysms have been studied and managed by many authors,1,3,7,11–13,15,18,23,27 their treatment still remains a demanding task. Surgical management of carotid-cavernous fistulas (CCF's) is often even more difficult than the treatment of intracavernous carotid aneurysms. In the past, occlusion of the CCF with a muscle embolus, intraluminal occlusion of the ICA with a Fogarty catheter, and/or extra- and intracranial ligation of the ICA were used for the treatment of intracavernous vascular lesions.8,14,18,19,22,24 Recently, the technique of extra- and intracranial ligation of the ICA has been employed in combination with a superficial temporal-middle cerebral artery bypass procedure for the treatment of intracavernous aneurysms.7,15

The elegant up-to-date technique of the detachable balloon catheter introduced via an arterial and/or venous route has resulted in occlusion of CCF's and preservation of carotid artery patency in over half the cases so treated.4 Thrombogenic techniques provide the ultimate treatment with which CCF's can be excluded and the ICA function preserved.16 Carotidcavernous fistulas were treated by a direct surgical approach and occlusion of the fistula by clipping as much as 20 years before the introduction of extracorporeal circulation and cardiac arrest.2 Cardiac arrest and hypothermia afforded safer conditions for a direct approach to vascular lesions located in the CS.12,17 The time available for the direct repair of the intracavernous ICA with the patient under cardiac arrest and deep hypothermia is relatively short, however, even for the most experienced surgeon.17

In the treatment of intracavernous aneurysms of the ICA and CCF's, selective occlusion of the lesion with preservation of carotid artery patency and avoidance of operative trauma to the third through sixth cranial nerves is the method of choice. Using the combination of a pterional28 and subtemporal approach6 and the exposure of the intrapetrous portion of the carotid artery,9 we have managed to achieve a safe direct approach to the CS without the addition of circulatory arrest and deep hypothermia.

Surgical Technique

The pterional approach28 was invariably used in all our patients, combined with the subtemporal approach6 and exposure of the intrapetrous part of the ICA9 whenever exposure of the entire CS was needed. In the latter case, the pterional approach was extended backward so that a larger portion of the temporal bone was made available for the bone flap. The petrous bone was exposed extradurally so that the exposure of the intrapetrous part of the ICA was feasible. The sphenoid wing was removed all the way to the clinoid process. The incision of the dura was made along the sphenoid wing down to the clinoid process, and extended to the optic nerve. Cerebrospinal fluid (CSF) was aspirated from the basal cisterns. The clinoid process was drilled off, and the optic canal opened from the superior and lateral aspect. It was necessary to remove the clinoid process and open the optic canal a few millimeters further forward in order to remove the bone between the optic nerve and the ICA. The ophthalmic artery and the anterior part of the intracavernous ICA were visualized. The incision of the dura was continued from the clinoid process back to the foramen spinosum, along the outer margin to the CS. The veins draining from the temporal lobe and the Sylvian fissure region into the CS were cauterized and divided. The temporal lobe was retracted and the tentorial edge exposed from the clinoid process backward to the entrance of the fourth nerve into the dura, below the tentorial edge. The third and fourth nerves were separated from the tentorial edge at the point where they enter between the layers of the lateral dural wall of the CS, and were followed all the way to the superior orbital fissure without opening the CS. The outer layer of the lateral dural wall of the CS was meticulously dissected from the third, fourth, and fifth nerves and turned in one piece.

Incision of the dura of the lateral wall of the CS was started at the entrance point of the fourth nerve, continued forward along the inner aspect of the tentorial edge to the entrance point of the third nerve, and extended along the superior orbital fissure and along the inner aspect of the lateral margin of the lateral wall of the CS backward to the foramen ovale. The most anterior part of the dural flap was turned in the first step by dissection of the third and fourth nerves.

Before the branches of the fifth cranial nerve were dissected, the intrapetrous segment of the ICA was exposed. Following Glasscock's instructions9 for exposure of the intrapetrous part of the ICA, three landmarks were very valuable: the middle meningeal artery, the arcuate eminence, and the greater superficial petrosal nerve. The middle meningeal artery was coagulated and ligated, and the greater superficial petrosal nerve was interrupted in order to gain more space and prevent traction of the geniculate ganglion.

Using a diamond burr and continuous irrigation and suction, we removed the bone over the ICA between the landmarks mentioned above. The ICA was unroofed from the anterior and superior aspect. The bone canal of the eustachian tube, located laterally to the canal of the intrapetrous ICA, was opened from the superior and medial aspect. The soft compartments of the eustachian tube were left intact. The entire circumference of the ICA inside the petrous bone was exposed and thus prepared for a possible temporal clipping in front of the entrance to the CS below the third division of the fifth nerve (V3). The fifth nerve was then dissected from the Gasserian ganglion peripherally by lifting the posterior part of the dural flap, which consisted of the outer layer of the CS lateral wall. The first division of the fifth nerve (V1) was followed to the supraorbital fissure, the second division (V2) to the foramen rotundum, and the motor branch (Vm) and V3 to the foramen ovale. Careful dissection allowed visualization of the V1, V2, Vm, and V3 divisions without opening the CS. During dissection of the nerves and turning the superficial layer of the dural flap (which remained attached to the tentorial edge, posterior to the entrance point of the fourth nerve and over the Gasserian ganglion), the bleeding was easily controlled by bipolar coagulation.

Subsequently, the ICA was dissected from the ophthalmic artery backward, along the sella turcica by packing the CS with Surgicel along the medial aspect of the ICA. The left and right CS were separated by occluding the intercavernous sinuses inside the sella turcica and above the most proximal part of the clivus. If arterial bleeding should occur, the blood flow can easily be interrupted by placing temporary clips on the petrous part of the ICA in front of the V3 division and peripherally in front of the ophthalmic artery. In no case was the ICA occluded for more than 30 minutes. Prior to intracavernous surgery, all the patients had good cross circulation through the anterior communicating artery (ACoA) from the healthy to the affected side. Vertebral angiography, with compression of the ipsilateral carotid artery in the neck, showed retrograde filling of the ICA through the posterior communicating artery (PCoA) in all four cases of CCF. These precautions were taken to ensure that the patients could tolerate a temporary occlusion of the ICA. Temporary interruption of the flow through the intracavernous part of the ICA afforded a much safer and more precise separation of the ICA and sixth nerve. For transient occlusion of the ICA, temporary Yaşargil clips FD 547 S and FD 548 S, with 30 to 41 gm/sq mm (0.30 to 0.40 N/sq mm) of pressure, were used. Clips of this pressure were unlikely to damage the intima of the ICA.

Dissection of the horizontal part of the intracavernous ICA was carried out most meticulously in order not to damage the sixth nerve, which runs close to the ICA and is the only nerve running through the CS proper.26 Venous bleeding in all the seven cases was easily controlled by packing the CS around the ICA with Surgicel. When the lesion had been clipped or resected and the ICA wall sutured, the temporary clips on the ICA were removed and the efficiency of the repair was checked. After ascertaining that the lesion had been excluded and an adequate flow through the ICA was preserved with no evidence of persisting arterial or venous bleeding, additional packing was placed in the CS around the ICA between individual nerves. The CS was covered with the dural flap and sewn down along the previous incision line.

The bone canal of the eustachian tube was covered with bone wax, and the intrapetrous part of the exposed ICA with a muscle flap taken from the temporal muscle, in order to prevent possible CSF leakage through the eustachian tube should it have been damaged. This procedure achieved patency of the eustachian tube. The dura over the brain was closed in a watertight manner. The bone flap was sutured to the bone edges and suction drains were inserted epidurally and subgaleally.

Summary of Cases
Patients

A summary of the course in patients treated for intracavernous vascular lesions is given in Table 1.

TABLE 1

Summary of course in patients operated on for intracavernous vascular lesions*

Case No.Sex, Age (yrs)LesionPreoperative Signs & SymptomsSurgeryPostop Carotid AngiographyPostoperative Signs & Symptoms
At 1 WeekAt 1 Year      
1M, 38aneurysm of rt ICA2-yr history of rt-sided retro-orbital pain; 2-wk paresis of rt III & IV nerves, & diplopiaclipping of aneurysmICA patient, aneurysm excludednonenone; resumed previous job
2F, 49aneurysm of1ACoA & lt ICAlong history of headache; sudden attack of severe headache & stiff neck, followed by aphasia & rt-sided hemiplegiaclipping of aneurysmsICA & ACoA patent, aneurysms excludeddysphasia; rt-sided hemiparesisslight dysphasia & hemiparesis, able to care for herself, resumed housekeeping
3F, 58giant aneurysm of rt ICA10-yr history of rt-sided retro-orbital pain; 4-yr history of slightly progressive paresis of rt III, IV, & VI nerves; 3-wk history of severe retro-orbital pain with rt-sided ophthalmoplegiaresection of aneurysm, reconstruction of ICA by suturingICA occluded, aneurysm excludedno pain, except for persisting ophthalmoplegia; no neurological deficitsdied 3 mos after surgery as result of infection
4M, 55lt-sided CCFloss of vision due to trauma; exophthalmos of lt eye, bruitreconstruction of ICA by suturingICA occluded, CCF excludedloss of vision, exophthalmos; no bruit or other neurological deficitsdied 10 days after surgery of massive pulmonary embolism
5M, 66lt-sided CCFexophthalmos of lt eye; bruitclipping of fistulaICA patent, CCF excludedno exophthalmos, bruit, or neurological deficitsnone; resumed previous job
6M, 23lt-sided CCFprogressive exophthalmos of lt eye, bruit & diplopia, paresis of lt VI nerve following injuryclipping of fistulaICA patent, CCF excludedno exophthalmos or bruit; paresis of VI nerve; no neurological deficitspersisting paresis of VI nerve; no neurological deficits; resumed previous job
7M, 25rt-sided CCFexophthalmos of rt eye, slightly progressive paresis of III, IV, and VI nerves; bruit, diplopiareconstruction of ICA by suturingICA patent, CCF excludedno exophthalmos or bruit; persisting diplopia & slight lt-sided hemiparesisnone; resumed previous job

The two aneurysms (both Group C lesions according to Jefferson's classification11) were situated on the anterior part of the ICA in the CS and did not require exposure of the entire CS or of the intrapetrous portion of the ICA. In these two patients (Cases 1 and 2), the anterior part of the CS was exposed. The ophthalmic artery, the parasellar segment of the ICA and the anterior part of the horizontal ICA segment below the third and fourth nerves, the nerves themselves, and the aneurysm on the anterior intracavernous segment of the ICA were dissected away and the aneurysm clipped.

Case 2 is presented to illustrate the exposure of the anterior part of the CS, and Case 6 as an example of exposure of the entire CS. In the rest of the patients (one case of giant aneurysm and four cases of CCF), the entire CS was explored and vascular lesions were excluded.

Case 2

This 49-year-old woman had suffered from frontal headaches since early youth. She experienced a sudden severe headache associated with vomiting, neck stiffness, and a brief lapse of consciousness. She presented at the department of neurology of another hospital with overt signs of subarachnoid hemorrhage (SAH), and was placed on medical therapy in the absence of focal signs.

Examination. The patient was found to be hypertensive with a blood pressure of 170/100 mm Hg, but otherwise was in good health. She recovered from the episode within a few days. Since she refused operative treatment, carotid angiography was not performed. Eleven days after the attack, she developed dysphasia and right-sided hemiparesis, and a left carotid angiogram disclosed an aneurysm of the ICA (Fig. 1). The patient was transferred to our department for operation. On admission she was conscious, aphasic, and hemiplegic on the right side. She did not undergo any additional right carotid and vertebral angiography prior to operation.

Fig. 1.
Fig. 1.

Case 2. Anteroposterior view of the left carotid angiogram showing the aneurysm on the medial aspect of the internal carotid artery in the cavernous sinus (arrow). Note the spasm of the anterior cerebral artery.

Operations. She was operated on by the left pterional approach. The intradural part of the left ICA was readily visualized and found to be perfectly normal. The medial aspect of the left optic nerve and the optic chiasm, however, were of a yellowish color. The left anterior cerebral artery (ACA) was dissected, and an aneurysm found on the ACoA was clipped.

At this stage, it was realized that the SAH had been caused by the aneurysm of the ACoA which had been missed by the left carotid angiography, and that the progressing clinical symptoms were due to a spasm resulting from the previous SAH. The aneurysm on the ICA situated in the CS was most probably responsible for the patient's long history of frontal headaches. Thus, it was decided to terminate the procedure at that stage and postpone clipping until the next session.

The patient underwent bilateral carotid and vertebral angiography 1 week later (Fig. 2). Cross circulation from the right (normal) to the left (affected) side through the ACoA, which had been preserved despite clipping of the aneurysm, was studied and proved adequate. Two weeks after the first surgical intervention, the second step was carried out using the same approach. The anterior part of the CS was opened to allow the clipping of the aneurysm (Fig. 3). A control left carotid angiogram was obtained 1 week following the second operation (Fig. 4).

Fig. 2.
Fig. 2.

Case 2. Anteroposterior (left) and lateral (right) views of the left carotid angiogram following the first operation. The aneurysm of the internal carotid artery in the cavernous sinus is still in place (arrow). The Yaşargil clip is on the aneurysm of the anterior communicating artery. The spasm of the anterior cerebral artery seen in Fig. 1 has resolved.

Fig. 3.
Fig. 3.

Case 2. Microsurgical exposure of the anterior part of the cavernous sinus showing the third and fourth nerves and the anterior (parasellar) part of the internal carotid artery (ICA) and the ophthalmic artery (a. opht.). Note the Yaşargil clip (arrow) on the medial aspect of the anterior part of the ICA at the site of the aneurysm. op = optic nerve.

Fig. 4.
Fig. 4.

Case 2. Anteroposterior (left) and lateral (right) views of the left carotid angiogram following the second operation. Yaşargil clips are seen on the aneurysms of the anterior communicating artery (ACoA) and of the internal carotid artery in the cavernous sinus. Note patency of the ACoA and absence of spasm of the anterior cerebral artery.

Postoperative Course. One month after the second operation, the patient was discharged from the department for further physiotherapy because of persisting right-sided paresis and dysphasia. One year after the second operation the patient remains slightly dysphasic and hemiparetic. She has no history of epileptic seizures and has never been on anticonvulsant medication. She is fully able to care for herself and can do all her housekeeping.

Case 6

This 23-year-old man was injured by a piece of wire which pierced his orbit just above the left eye. There was a swelling of his left eyelid with a concomitant onset of double vision. The next day he noticed a bruit on the left side of his head. He was followed by a neurologist on an out-patient basis. One year after the trauma, when the bruit became more annoying, the patient consented to admission to the department of neurosurgery for a diagnostic evaluation of his disorder.

Examination. He presented with loss of function of the left sixth nerve. There were no other neurological signs. The bruit was distinctly audible over the left side of the head. Left carotid angiography revealed a CCF (Fig. 5). The patient refused surgery. One year later (2 years after the trauma), he was readmitted because he found it more and more difficult to bear the bruit. He consented to surgical therapy.

Fig. 5.
Fig. 5.

Case 6. Anteroposterior (left) and lateral (right) views of the left carotid angiogram showing the carotid-cavernous fistula.

Operation. The whole CS was exposed along with all its normal structures except the sixth nerve, which was not found. Since the CCF was situated ventrally on the anterior part of the horizontal ICA segment, occlusion was performed by clipping (Fig. 6).

Fig. 6.
Fig. 6.

Case 6. Microsurgical exposure of the entire left cavernous sinus showing all its structures but the sixth nerve. Note the Yaşargil clip (arrow) on the medial aspect of the internal carotid artery (ICA) in Parkinson's triangle. op = optic nerve; a. opht. = ophthalmic artery.

Postoperative Course. The bruit disappeared and the postoperative course was uneventful. A control left carotid angiogram performed 1 week after surgery showed no CCF and patency of the ICA (Fig. 7). Two weeks after surgery, the patient was discharged home, satisfied with his having been relieved of the annoying bruit, although there was no return of the lost function of the left sixth nerve. On resuming his previous job 3 months later, he was free of symptoms, even of dysesthesias on the left side of the face, but suffered from persisting loss of function of the left sixth nerve.

Fig. 7.
Fig. 7.

Case 6. Anteroposterior (left) and lateral (right) views of the left carotid angiogram showing the absence of the carotid-cavernous fistula (CCF). Compare with Fig. 5. Yaşargil and Sugita clips were used for occlusion of the CCF. Excessive packing of the cavernous sinus with Surgicel around the internal carotid artery (ICA) created an indentation of the arterial wall of the ICA, impinging on the lumen of the artery.

Discussion

Thorough anatomical studies of the CS by a number of authors,1,10,11,17,20,26 the daring and successful direct surgical approach to the CS performed by Browder,2 the impressive surgical interventions by Parkinson17 and Johnston,12 and our own anatomical studies of the CS on cadavers have encouraged us to undertake a direct operative attack of the CS. A combination of three approaches, the pterional,28 the subtemporal,6 and exposure of the intrapetrous portion of the carotid artery, has made it feasible to attack the CS from all sides; thus, good control of the arterial flow through the CS was obtained by temporary exclusion of various segments of the intracavernous ICA. By aspirating CSF, enough space was obtained in all our patients so that they needed no additional medical brain dehydration.

Temporary selective occlusion of the intracavernous segment of the ICA by the application of temporary clips on the ICA, at the point where it enters the CS under the V3 division and centrally to the ophthalmic artery, permits a risk-free direct repair of the vascular lesion without deep hypothermia or extracorporeal circulation with cardiac arrest. Using the technique described above, we have never been pressed for time. Although the triangular space between the third and fourth nerves above, and the V1 division and the sixth nerve below (described by Parkinson17) represents a most trustworthy surgical landmark, we preferred to dissect away at least the third and fourth nerves before entering the CS.

Our preoperative carotid angiograms, except those for Cases 1 and 2, failed to localize the exact site of the lesion on the ICA. However, vertebral angiography with compression of the ipsilateral carotid artery in the neck showed retrograde filling of the ICA through the PCoA, and the location of the CCF was identified in all four cases as being on the horizontal part of the intercavernous ICA.

In Case 3 there was no retrograde vertebral filling of the aneurysm. A double-lumen carotid catheter for distal injection of contrast material by temporary balloon occlusion of the ICA through the proximal lumen was not available at that time; therefore, the precise origin of the aneurysm was not identified preoperatively. In the management of the CCF much time had to be devoted to an exact and careful separation of the third and fourth nerves and the V1, V2, V3, and Vm branches of the fifth nerve. We have learned from experience that dissection of the nerves is the most demanding and time-consuming task of the entire procedure. The nerves, especially the fourth nerve, are very delicate and when pathologically stretched and displaced they are easily mistaken for dural fibers running longitudinally along them. Isolation of the ICA, packing it within the CS with Surgicel, the control of bleeding as well as the identification of the vascular lesion, the surgical repair, and even dissection of the sixth nerve constituted less of a problem than did the dissection of the third and fourth nerves and the V1, V2, V3, and Vm branches of the fifth nerve in the lateral dural wall of the CS. It should be stressed that no matter how thorough anatomical studies on cadavers are,10,20,26 they merely serve as indispensable guidelines rather than absolute standards for the dissection of structures running through the wall and the lumen of the living CS that is subjected to pathological changes.

We find that the intrapetrous exposure of the ICA is not difficult after having become well trained in Glasscock's technique.9 The complete exposure of the ICA from the petrous bone to the supraclinoid portion offers the possibility to mobilize the artery for better access to the lesion if it is on the underside of the ICA. We believe that unroofing the ICA in petrous bone is superior to the exposure of the artery in the neck because it entails only a single smaller operating field and hence less possibility of infection. Even more importantly, the exposure of the last peripheral intrapetrous part of the ICA is essential for the safe manipulation of the whole intracavernous segment of the ICA when necessary.

The two fatal outcomes in our series of seven patients (Cases 3 and 4) support our view that the procedure should not be contemplated in poor-risk or elderly patients because of the long operation required for repair of the ICA, which ranged from 3 hours in Case 1 to 10 hours in Cases 6 and 7. For those at risk, the elegant and safe treatment of intracavernous vascular lesions with a detachable balloon catheter4 and/or thrombogenic techniques16 should yield very good results and will remain an excellent alternative to direct repair. The disadvantage of direct intracavernous surgery may be also in the intraoperative interruption of the venous drainage from the brain to the CS. We believe that in Case 7 the impaired venous drainage from the temporal lobe and from a larger area of the hemisphere in the basal direction led to the development of brain edema and transient hemiparesis. Detailed studies of the venous flow via the CS and intercavernous sinuses5,21,25 and of the venous drainage from the brain to the CS will be required to further justify direct intracavernous surgery.

In summary, the results of our series speak in favor of the direct intracavernous repair of aneurysms which, if treated in this manner in the early stages before they continue to enlarge, are less likely to be difficult to manage. This method has proven to be a risk-free procedure, feasible without deep hypothermia, extracorporeal circulation, or cardiac arrest. The technique is selective and permits total removal of intracavernous vascular lesions with the preservation of the ICA patency and avoidance of operative traumatization of the nerves.

Because of the hazards there has been a tendency to avoid direct repair of the intracavernous vascular lesions with concomitant involvement of the third through sixth cranial nerves secondary to trauma or tumor. However, it is likely that this procedure, especially in cases of small aneurysms and tumors invading the CS, will be the treatment of choice for some time.

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This paper was presented at the Seventh International Congress of Neurological Surgery, July 12–18, 1981, Munich, Germany.

Article Information

Address reprint requests to: Vinko Dolenc, M.D., University Department of Neurosurgery, University Medical Center, Zaloska 7, 61105 Ljubljana, Yugoslavia.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 2. Anteroposterior view of the left carotid angiogram showing the aneurysm on the medial aspect of the internal carotid artery in the cavernous sinus (arrow). Note the spasm of the anterior cerebral artery.

  • View in gallery

    Case 2. Anteroposterior (left) and lateral (right) views of the left carotid angiogram following the first operation. The aneurysm of the internal carotid artery in the cavernous sinus is still in place (arrow). The Yaşargil clip is on the aneurysm of the anterior communicating artery. The spasm of the anterior cerebral artery seen in Fig. 1 has resolved.

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    Case 2. Microsurgical exposure of the anterior part of the cavernous sinus showing the third and fourth nerves and the anterior (parasellar) part of the internal carotid artery (ICA) and the ophthalmic artery (a. opht.). Note the Yaşargil clip (arrow) on the medial aspect of the anterior part of the ICA at the site of the aneurysm. op = optic nerve.

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    Case 2. Anteroposterior (left) and lateral (right) views of the left carotid angiogram following the second operation. Yaşargil clips are seen on the aneurysms of the anterior communicating artery (ACoA) and of the internal carotid artery in the cavernous sinus. Note patency of the ACoA and absence of spasm of the anterior cerebral artery.

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    Case 6. Anteroposterior (left) and lateral (right) views of the left carotid angiogram showing the carotid-cavernous fistula.

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    Case 6. Microsurgical exposure of the entire left cavernous sinus showing all its structures but the sixth nerve. Note the Yaşargil clip (arrow) on the medial aspect of the internal carotid artery (ICA) in Parkinson's triangle. op = optic nerve; a. opht. = ophthalmic artery.

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    Case 6. Anteroposterior (left) and lateral (right) views of the left carotid angiogram showing the absence of the carotid-cavernous fistula (CCF). Compare with Fig. 5. Yaşargil and Sugita clips were used for occlusion of the CCF. Excessive packing of the cavernous sinus with Surgicel around the internal carotid artery (ICA) created an indentation of the arterial wall of the ICA, impinging on the lumen of the artery.

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