Transcavernous Approach for Infraclinoid Internal Carotid Aneurysms

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Due to the location, there are many surgical problems and pitfalls in the treatment of infraclinoid internal carotid artery (ICA) aneurysms. It is impossible to evaluate exactly from the preoperative angiogram whether the aneurysm is located in the cavernous sinus (CS), in the carotid cave, or around the dural ring. Therefore, cervical internal carotid artery (ICA) or petrous ICA has been exposed to control bleeding from aneurysms during surgery. The cavernous ICA should be exposed not only in order to accurately perform aneurysmal neck clipping but also to be prepared for possible premature bleeding. In this paper, we report on the surgical technique for accurate clipping of infraclinoid aneurysms called the transcavernous approach. The surgical technique is as foliows: (1) Semisitting position to decrease venous bleeding from the cavernous sinus. (2) Combined epi- and subdural approach to remove the anterior clinoid process and to open the optic cannal. At the final stage of this approach, drilling of bony structures should be done subdurally so as not to injure the ICA. (3)It is necessary to cut the falciform ligament and to open the optic dural sheath. (4) The C4 segment of the ICA is exposed for temporary clipping of the ICA before cutting the dural ring. (5)Bleeding from the CS is controlled by packing with Biobond-soaked Oxycel. (6)The Sugita curved blade"L"shaped fenestrated clip is useful. During the last 12 years, 39 infraclinoid aneurysms were treated by this approach. Thirty four aneurysms were clipped, whereas one was trapped and four were trapped and the cavernous ICA was reconstructed using a saphenous vein interposition graft. Thirty three patients (92%) recovered and returned to the preveous jobs. One remained vegetative because of vasospasm. Two patients died from vasospasm and agranulocytosis.
The Japanese Society on Surgery for Cerebral Strokeの論文

Transcavernous Approach for Infraclinoid Internal Carotid Aneurysms

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