gms | German Medical Science

Objective: Paraclinoidal ICA-aneurysms constitute a challenge to surgeons. Some neurosurgeons have advocated the application of a contralateral approach, claiming that the anatomy of the paraclinoid region is best exposed from the contralateral side. Small case-series have been published reporting favourable results using this approach. However, there is a lack of systematic analyses concerning epidemiological, clinical, anatomical and surgical characteristics, including pitfalls, limitations and complications that help surgeons to choose the optimal approach. We here review the literature in order to identify common features and provide general recommendations.

Methods: Relevant articles were identified in a Pubmed search: \'7b(aneurysm OR approach OR approaches) AND (contralateral OR unilateral OR unilateral)\'7d. The articles were then screened to exclude those in which no paraclinoid aneurysms had been treated, no contralateral approaches were used, no epidemiological or surgical data from patients were available.

Results: Among 19 relevant publications, 115 paraclinoid aneurysms were operated via contralateral approach. Patient age ranged from 19 to 79-years and the number of women exceeded men. None of the reported aneurysm had ruptured preoperatively. Aneurysm size varied between 2-10 mm and only three articles reported larger or giant aneurysms. Aneurysm location was predominantly at the origin of the ophthalmic artery (81%), followed by the superior hypophyseal artery origin (15%) and carotid cave (4%). All aneurysm protruded from the medial surface of the ICA. Intraoperatively, authors report that only minimal or even no optic nerve mobilisation was required. In 8 cases the tuberculum sellae and planum sphenoidale needed to be partially removed. Successful aneurysm occlusion was achieved in 112 cases, while 3 ophthalmic aneurysms could be wrapped only. Reported complications included: visual deterioration (6%), CSF fistula (1.7%), wound infection (1.7%), vasospasm (2.4%) artery dissection (0.8%), infarction (0.8%) and anosmia (0.8%).

Conclusion: A contralateral approach is feasible and effective to treat medially pointing, unruptured, preferably small paraclinoid ICA-aneurysms. It reduces the need of optic nerve mobilisation or anterior clinoidectomy and thereby could potentially reduce the risk of visual impairment. If patient are carefully selected, surgery is associated with good outcomes and low morbidity and mortality.