Direct surgical management of large bulbous and giant aneurysms involving the paraclinoid segment of the internal carotid artery: report of 29 cases.

BACKGROUND: Twenty-nine patients with large bulbous and giant aneurysms of the paraclinoid segment of the internal carotid artery (ICA) were operated on, using Dolenc's combined epi- and subdural approach, between 1985 and 1994. Ages ranged from 25 to 79 (83% female; 17% male).
METHODS: Proximal control was established in all patients through either an extracranial or petrous carotid exposure. The aneurysm was approached through a wide exposure by removing the anterior clinoid extradural. All but one aneurysm was clipped directly. A saphenous vein graft from the petrous-to-supraclinoid bypass was performed in this remaining case.
RESULTS: Surgical morbidity was assessed at 20%. One patient developed a postoperative subdural hematoma and remained severely disabled. Two patients developed permanent third nerve palsy. One patient experienced severe disabling cognitive deficit. One patient died from complications related to a stroke. One patient developed transient diabetes insipidus. Visual outcome, which was assessed separately, was unimproved in 50% of the cases during a follow-up period that averaged 7 years.
CONCLUSIONS: With the development of cranial base procedures such as Dolenc's combined epi- and subdural approach, large and giant aneurysms of the paraclinoid segment can be directly clipped with acceptable morbidity, allowing the ICA to remain patent.