Anterior petroclinoid fold fenestration: an adjunct to clipping of postero-laterally projecting posterior communicating aneurysms

Proximally located posterior communicating artery (PCoA) aneurysms, projecting postero-laterally in proximity to the tentorium, may pose a technical challenge for microsurgical clipping due to obscuration of the proximal aneurysmal neck by the anterior petroclinoid fold. We describe an efficacious t...

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Bibliographic Details
Published in:Neurosurgical review 2014-10, Vol.37 (4), p.637-641
Main Authors: Nossek, Erez, Setton, Avi, Dehdashti, Amir R., Chalif, David J.
Format: Article
Language:English
Subjects:
Carotid Artery, Internal - pathology
Carotid Artery, Internal - surgery
Craniotomy - adverse effects
Craniotomy - methods
Endovascular Procedures - methods
Humans
Intracranial Aneurysm - pathology
Intracranial Aneurysm - surgery
Medicine
Medicine & Public Health
Microsurgery - methods
Neurosurgery
Neurosurgical Procedures - adverse effects
Neurosurgical Procedures - methods
Oculomotor Nerve Diseases - etiology
Oculomotor Nerve Diseases - therapy
Original Article
Posterior Cerebral Artery - pathology
Posterior Cerebral Artery - surgery
Postoperative Complications - therapy
Treatment Outcome
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Summary:Proximally located posterior communicating artery (PCoA) aneurysms, projecting postero-laterally in proximity to the tentorium, may pose a technical challenge for microsurgical clipping due to obscuration of the proximal aneurysmal neck by the anterior petroclinoid fold. We describe an efficacious technique utilizing fenestration of the anterior petroclinoid fold to facilitate visualization and clipping of PCoA aneurysms abutting this aspect of the tentorium. Of 86 cases of PCoA aneurysms treated between 2003 and 2013, the technique was used in nine (10.5 %) patients to allow for adequate clipping. A 3 mm fenestration in the anterior petroclinoid ligament is created adjacent and lateral to the anterior clinoid process. This fenestration is then widened into a small wedge corridor by bipolar coagulation. In all cases, the proximal aneurysm neck was visualized after the wedge fenestration. Additionally, an adequate corridor for placement of the proximal clip blade was uniformly established. All cases were adequately clipped, with complete occlusion of the aneurysm neck and fundus with preservation of the PCoA. There were two intraoperative ruptures not related to creation of the wedge fenestration. One patient experienced post-operative partial third nerve palsy, which resolved during follow-up. We describe a technique of fenestration of the anterior petroclinoid fold to establish a critical and safe corridor for both visualization and clipping of PCoA aneurysms.
ISSN:0344-5607
1437-2320
DOI:10.1007/s10143-014-0554-6