A combined epi- and subdural direct approach to carotid-ophthalmic artery aneurysms.

A series of 14 patients with a carotid-ophthalmic artery aneurysm were treated operatively. In five patients the aneurysms were large, but only one of these had ruptured; four of these patients had symptoms of mass lesions. The remaining nine patients were operated on for a ruptured aneurysm; seven had subarachnoid hemorrhage due to the carotid-ophthalmic artery aneurysm and two had bleeding from another aneurysm in the presence of an asymptomatic carotid-ophthalmic artery aneurysm. All patients were treated by a combined epi- and subdural direct surgical approach, which excluded the carotid-ophthalmic artery aneurysm from the circulation and made possible the preservation of the adjacent structures. Two patients died: one a few hours after surgery from a massive thromboembolism of the pulmonary artery and another 2 months after surgery as a result of gastrointestinal bleeding. All the other patients showed postoperative improvement in symptoms and signs. This report focuses on a modified direct surgical approach involving exposure of the internal carotid artery proximal to the lesion, and of the ophthalmic artery, which is of primary importance in securing safe and complete occlusion of a carotid-ophthalmic artery aneurysm. Removal of individual bone structures at the base of the skull provides a better and safer exposure of the central segment of the internal carotid artery than does excessive and hazardous retraction of the brain.