5 Diagnosis Giant intracavernous aneurysm and carotid ophthalmic aneurysm Problems and Tactics A giant intracavernous aneurysm and a carotid ophthalmic aneurysm were found at the left internal carotid artery (ICA) in a man complaining of left retroorbital pain and oculomotor nerve palsy. Despite the difficulties in direct neck clipping, a direct surgical approach was chosen because of no guarantee of future subarachnoid hemorrhage and in order to decompress the oculomotor nerve. Keywords Cavernous sinus, intracavernous aneurysm, carotid ophthalmic aneurysm, neck clipping A 55-year-old man had complained of left retroorbital pain and left oculomotor nerve palsy. A carotid angiography showed a giant intracavernous aneurysm and a carotid ophthalmic aneurysm in the left ICA (Fig. 5–1A,B). The patient was placed in the supine position. The head was elevated ~20 degrees and rotated to the contralateral side ~20 degrees. The left cervical carotid artery was exposed for possible temporary occlusion as well as for intraoperative angiography. A left frontotemporal craniotomy was performed. After opening the dura, the subdural approach was performed. The carotid ophthalmic aneurysm and the giant intracavernous aneurysm were not seen initially. Then the combined epidural and subdural approach2,5,6 was employed. The anterior clinoid process was drilled out extradurally and the optic canal unroofed. After removal of the clinoid process, it became possible to see the distal neck of the carotid ophthalmic aneurysm. The optic sheath was opened over the optic nerve and was cut just distally to the ophthalmic artery. The left oculomotor nerve was compressed by the giant aneurysm so the nerve was decompressed from the entrance point to the lateral surface of the cavernous sinus to the superior orbital fissure. The dural ring was opened to expose the C3 segment of the ICA. Packing with pieces of Oxycel® controlled bleeding from the cavernous sinus. The small carotid ophthalmic aneurysm was clipped first and the giant intracavernous aneurysm was trapped between the cervical ICA and the supraclinoid ICA under hypothermia barbiturate brain protection and systemic heparinization. Because the giant aneurysm was located at the lateral surface of the C3 segment of the ICA, Yasargil curved-bladed clips were applied at the neck of the giant aneurysm from the C3 segment to the C4 segment parallel to the ICA (Fig. 5–2
Giant Intracavernous Aneurysm and Carotid Ophthalmic Aneurysm
Clinical Presentation
Surgical Technique
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