Prediction of the difficulty of proximal vascular control using 3D-CTA for the surgical clipping of internal carotid artery-posterior communicating artery aneurysms.

Publisher: American Association of Neurological Surgeons Country of Publication: United States NLM ID: 0253357 Publication Model: Electronic-Print Cited Medium: Internet ISSN: 1933-0693 (Electronic) Linking ISSN: 00223085 NLM ISO Abbreviation: J Neurosurg Subsets: MEDLINE

Publication: Charlottesville, VA : American Association of Neurological Surgeons
Original Publication: Chicago [etc.]

Carotid Artery, Internal/*diagnostic imaging ; Carotid Artery, Internal/*surgery ; Intracranial Aneurysm/*diagnostic imaging ; Intracranial Aneurysm/*surgery ; Neurosurgical Procedures/*methods ; Posterior Cerebral Artery/*diagnostic imaging ; Posterior Cerebral Artery/*surgery; Adult ; Aged ; Aged, 80 and over ; Arterial Occlusive Diseases/surgery ; Carotid Artery Diseases ; Cerebral Angiography ; Computed Tomography Angiography ; Female ; Humans ; Imaging, Three-Dimensional ; Male ; Middle Aged ; Neuroimaging/methods ; Predictive Value of Tests ; ROC Curve ; Retrospective Studies ; Skull Base/surgery

Objective: During surgical clipping of internal carotid artery (ICA)-posterior communicating artery (PCoA) aneurysms, proximal vascular control (PVC) is difficult to achieve in some cases because of variations in the anatomy of this type of aneurysm and its parent arteries. The authors investigated morphometric features that may be predictive for the necessity of anterior clinoidectomy (ACL) or cervical ICA exposure for PVC.
Methods: The authors retrospectively reviewed 65 patients with an ICA-PCoA aneurysm treated with clipping during the previous 3 years. The factors considered for assessing the difficulty of attaining PVC included the following: the maximum diameter of the aneurysm; the distance between the tip of the anterior clinoid process (ACP) and the proximal aneurysmal neck; the presence of calcification at the ophthalmic segment of the ICA; and the angles between the communicating segment of the ICA and the ophthalmic segment of the ICA and a line perpendicular to the cranial base, which reflect the tortuosity of the ICA. These parameters were measured based on preoperative CTA results.
Results: In a total of 21 patients (32.3%), PVC was difficult to perform with the usual pterional approach. In 6 patients, temporary artery occlusions (TAOs) were difficult to achieve because of severe atherosclerotic wall changes in the ophthalmic segment of the ICA. For 15 patients, the ACPs overhanging the ophthalmic segment of the ICA obstructed the ability to secure a space for TAO. In the 21 patients with PVC difficulty, ACL alone, cervical ICA exposure alone, and both ACL and cervical ICA exposure were conducted in 6, 8, and 7 patients, respectively. Multivariate analysis with binary logistic regression revealed that the maximum diameter of the aneurysm (p = 0.041), the distance between the proximal neck of the aneurysm and the ACP tip (p = 0.002), and calcification of the ICA ophthalmic segment (p = 0.001) were significant predictive factors for difficulties with PVC. A receiver operating characteristic curve analysis revealed that a distance between the proximal aneurysmal neck and the ACP tip of ≤ 5.4 mm was the best cutoff value for predicting the difficulty of attaining PVC (area under the curve 0.800, sensitivity 80.0%, specificity 80.0%).
Conclusions: A short distance between the proximal aneurysmal neck and the ACP tip and the presence of calcification at the ophthalmic segment of the ICA on preoperative CTA are helpful for predicting the difficulty of achieving PVC.

Keywords: aneurysms; anterior clinoid process; anterior clinoidectomy; internal carotid artery; posterior communicating artery; vascular disorders

Date Created: 20200411 Date Completed: 20210730 Latest Revision: 20240810

20240812

10.3171/2020.1.JNS192728

32276244