Left orbitocranial modified orbitozygomatic craniotomy for ophthalmic aneurysm
This case illustrates the clipping of an ophthalmic aneurysm using a left orbitocranial modified orbitozygomatic craniotomy.
Incidental note made of aneurysm after workup for tinnitus year prior. No neurological symptoms. Family history significant for strokes and aneurysms. 56 year old Female.
The orbital contents are gently protected while the osteotomy is performed using a sagittal saw or osteotome. The medial border of the osteotomy is the supraciliary nerve, while the lateral border is the frontozygomatic suture. After the craniotomy, the spenoid ridge is flattened and the dural opening is based medially, retracting the orbital contents to allow access to the anterior cranial floor.
Conservative medical management with serial observation Interventional radiology for coiling
Supine/Flat Turning: RIGHT
A curvilinear skin incision was made behind the hairline, was chosen for sufficient exposure and cosmetic effect.
After the induction of general anesthesia, the patient's head was turned to the right and the left side of the head was prepped in the usual fashion. Curvilinear skin incision was made behind the hairline. After lumbar drain catheter was placed in the L3-L4 interspace with spinal fluid obtained under normal pressure allowed to drain intermittently throughout the procedure to allow for brain relaxation Orbitocranial orbitozygomatic modified approach to anterior cranial skull base was performed removing material and a craniotomy with single piece using the high-speed drill, followed by intradural drilling of the anterior clinoid process using 1 and 2 mm diamond and cutting burs to allow for access to the proximal internal carotid artery. Once this was done, intradural microdissection was utilized to identify an ophthalmic segment aneurysm. Careful preservation of the optic nerve and ophthalmic artery was then accomplished with complete occlusion of the aneurysm with titanium aneurysm clips. Following confirmation of occlusion of the aneurysm, an excellent flow in the proximal and distal carotid artery and ophthalmic artery and its branches using ICG video angiography, the wound was copiously irrigated. Hemostasis was excellent. Dura was loosely approximated and covered with synthetic dural graft. The bone was replaced using titanium plates and screws. The temporalis muscle was closed using sutures as well for the skin. There were no complications.
Patient did well post-operatively. CT showed normal postoperative changes. Patient discharged home POD 2.
At 6 week follow up patient was doing well and had no neurological symptoms.
Pearls and Pitfalls
Surgical treatment of ophthalmic aneurysms requires precise anatomical knowledge of the relationship of the anterior clinoid to the carotid artery and optic nerve. Excellent results can be achieved with microsurgical clipping of ophthalmic artery aneurysms.
The dural incisions for intradural anterior clinoid process removal. The dashed lines along the medial sphenoid wing and anterior clinoid remnant represent the dural incision. An extension of this incision is carried through the falciform ligament and lateral optic nerve ensheathment to decompress and mobilize the optic nerve. Exposure following intradural anterior clinoid process removal and optic strut drilling. The dashed line represents the dural incision along the subarachnoid space surrounding the optic nerve within the optic canal. The optic nerve is then markedly decompressed and mobile; a stitch is placed at the intracranial end of the opening of the optic canal dura, and retracted in the direction of the arrow to allow a completely open view of the dural ring and the ophthalmic artery origin.