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Direct clipping for large and giant juxta dural ring internal carotid (IC) aneurysms is a difficult neurosurgical procedure. We describe the importance of skull base surgery techniques and the usefulness of the suction-decompression method for direct clipping of these aneurysms. We have treated 9 large (15-24 mm) and 6 giant (25 mm≤) aneurysms in this region by direct clipping during the past 6 years. The patients presented with subarachnoid hemorrhage in 4 cases, visual disturbance in 7 cases and in 4 cases the aneurysms were incidentally discovered. Preoperative ipsilateral IC balloon test occlusion showed neurological symptoms in 2 cases. Proximal control of IC during surgery was performed either by intravascular balloon catheter or direct exposure in the neck. A conventional pterional craniotomy was performed, the anterior clinoid process and optic canal and strut were drilled off intradurally, and the dural ring was clearly delineated. Mobilization of IC and the optic nerve became easier with these procedures. Before clipping, suction-decompression was commonly used to reduce aneurysmal size enough to facilitate dissection from the surrounding structures. Multiple clips were used: fenestrated clips in 11 cases and straight clips in 4 cases. Although 1 case had postoperative ischemic complication in the ipsilateral cerebral hemisphere, complete clipping was performed in the other 14 cases without ischemic complication. Postoperative improvement of visual symptoms was observed in 4 cases in which surgery was performed within 3 months of onset. In conclusion, skull base surgery techniques and the suction-decompression method play important roles in obtaining good surgical outcomes for direct clipping of large and giant juxta dural ring IC aneurysms.

Direct Clipping for Large and Giant Juxta Dural Ring Internal Carotid(IC) Artery Aneurysms.