title: Surgical management of large and giant intracavernous and paraclinoid aneurysms.
abstract: BACKGROUND
  Due to their location, large and giant intracavernous and paraclinoid aneurysms remain a challenge for vascular neurosurgeons. We identified characteristics, surgical indications and treatment strategies of large and giant intracavernous and paraclinoid aneurysms in 36 patients.
  
  
  METHODS
  The pterional approach was routinely used. The cervical internal carotid artery was exposed for proximal control of parent vessel and retrograde suction decompression. Paraclinoid aneurysms were directly clipped, intracavernous pseudoaneurysm was repaired and the intracavernous aneurysms were trapped with extracranial-intracranial bypass of saphenous vein graft. Intraoperative electroencephalogram (EEG) and somatosensory evoked potential (SSEP) monitoring were used to detect cerebral ischemia during the temporary occlusion of parent arteries. Microvascular Doppler ultrasonography was used to assess blood flow of the parent and branch vessels. Endoscopy was helpful particularly in dealing with internal carotid artery posterior wall aneurysms. Postoperative digital subtraction angiography (DSA) was performed in 33 of the 36 patients.
  
  
  RESULTS
  Thirty-two paraclinoid aneurysms were directly clipped, 1 intracavernous pseudoaneurysm was repaired and the other 3 intracavernous aneurysms were trapped with revascularization. Except for two patients who died in the early postoperative stage, 34 patients' follow-up was 6 - 65 months (mean 10 months) and a Glasgow Outcome Scale score of 4 to 5 at discharge. At the 6-month follow-up examination, Rankin Outcome Scale scores were 0 to 2 in 32 patients. EEG and SSEP monitoring changed in six patients. Twelve clips were readjusted when insufficient blood flow in parent and branch vessels was detected. Three posterior wall aneurysms were clipped.
  
  
  CONCLUSIONS
  Intracavernous aneurysms not amenable to endovascular treatment should be treated surgically and surgical treatment is the first option for paraclinoid aneurysms. The temporary parent vessel occlusion, retrograde suction decompression, endoaneurysmectomy, parent vessel reconstruction, vascular anastomosis, electrophysiological monitoring, Doppler ultrasonography and endoscopy are essential techniques in the treatment of the large and giant intracavernous and paraclinoid aneurysms.
authors.affiliation: Department of Neurosurgery, General Hospital of People's Liberation Army, Beijing 100853, China. shjwkk@sina.com
authors.forename: Bai-nan
authors.initials: BN
authors.lastname: Xu
authors.forename: Zheng-hui
authors.initials: ZH
authors.lastname: Sun
authors.forename: Jin-li
authors.initials: JL
authors.lastname: Jiang
authors.forename: Chen
authors.initials: C
authors.lastname: Wu
authors.forename: Ding-biao
authors.initials: DB
authors.lastname: Zhou
authors.forename: Xin-guang
authors.initials: XG
authors.lastname: Yu
authors.forename: Bao-min
authors.initials: BM
authors.lastname: Li
mesh_terms: D000328:Adult; D000368:Aged; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D002533:Cerebral Angiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002532:Intracranial Aneurysm / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome