A combined transorbital-transclinoid and transsylvian approach to carotid-ophthalmic aneurysms without retraction of the brain.

A series of 138 patients with 143 carotid-ophthalmic aneurysms (COAs) have been treated by direct surgical approach over the past 15 years. In 5 cases the COAs were bilateral and in 15 cases either one or more aneurysms were associated with a COA. Of the 143 COAs, 87 were small, 41 large and 15 were giant. Seventy-four COAs bled, while 69 were diagnosed either incidentally or else manifested themselves through neurological deficits resulting from compression of the adjacent structures by the aneurysms. Visual deficits were diagnosed in all the patients with large/giant COAs and in 27 patients with small COAs. Of the whole series of patients operated on for COAs, 2 died after surgery. Two patients had endocrinological deficits, 2 had hemiparesis, 36 had the same visual deficits as prior to surgery, whereas in 47 patients the visual function improved. Of all the 138 patients, 96 remained without neurological deficits, and the 36 patients with the same visual deficits as preoperatively also showed no neurological deficits after surgery and hence they were able to resume their previous way of life. Vasospasm did not occur in patients with COA(s) only, but was observed in 6 out of 15 patients with multiple aneurysms where subarachnoid hemorrhage (SAH) had occurred due to a rupture of an aneurysm other than the COA. There has been a major change in the surgical approach to COAs, from the classical pterional intradural approach to the transorbital-transclinoid and transsylvian approach which is described in this report. The latter approach provides ample space for proximal and distal control of the internal carotid artery (ICA) and makes it possible to deal with demanding large/giant COAs safely. In the series presented, there was no case of premature rupture of the aneurysm. Moreover, since we started using the described approach to COAs, retraction of the brain has not been necessary, regardless of the size of the aneurysm.