Clinoidectomía anterior intradural para clipado de aneurisma paraclinoideo izquierdo: video quirúrgico

Clinoidectomía anterior intradural para clipado de aneurisma paraclinoideo izquierdo: video quirúrgico
2do Premio Video "Dr. Julio A. Ghersi", 46º Congreso Argentino de Neurocirugía

Álvaro Campero¹, Matías Baldoncini^2
1Servicio de Neurocirugía Hospital Padilla, Tucumán, Argentina.
²Servicio de Neurocirugía Hospital de San Fernando, Buenos Aires, Argentina.

RESUMEN
Introducción: Los aneurismas paraclinoideos representan un verdadero desafío microquirúrgico para su resolución.
Objetivo: Presentamos el caso de una mujer de 43 años de edad con cefalea, detectando en angiografía aneurisma paraclinoideo izquierdo.
Material y métodos: Se realizó abordaje pterional izquierdo y exposición de carótida interna a nivel cervical, durotomía arciforme con apertura de cisterna silviana hacia cisterna carotídea. Se expone la apófisis clinoides anterior, observándose en el video, el aneurisma naciendo del segmento clinoideo de la arteria carótida interna, siendo imposible el clipado de la misma sin clinoidectomía anterior. Se secciona la duramadre desde medial respecto al conducto óptico hasta la apófisis clinoides. Se realiza fresado en la base de la apófisis clinoides para exponer el anillo dural distal.
Se libera la carótida en el segmento clinoideo a través de la sección del anillo dural distal para poder movilizarla. Identificado el cuello distal y proximal del aneurisma, se comienza la reconstrucción colocando un clip a 90° en dirección anteroposterior, un segundo clip en dirección posteroanterior y al punzar el aneurisma se constata flujo aneurismático presente. Se coloca un tercer y cuarto clip en tándem desde la proximidad a la carótida interna hacia el domo del aneurisma. Finalmente se posiciona un quinto clip curvo sobre los anteriores para darles mayor presión de cierre.
Resultados: Se observa angiografía postoperatoria con exclusión completa el aneurisma con adecuada permeabilidad carotidea. El período postoperatorio fue excelente, sin déficit neurológico. La paciente brindo consentimiento para publicar sus imágenes y videos.

Palabras claves: Aneurisma Paraclinoideo; Base de Cráneo; Clinoidectomía Intradural; Clipado en Tándem

ABSTRACT
Introduction: Paraclinoid aneurysms represent a true microsurgical challenge.
Objective: We present the case of a 43-year-old woman with headache, in whom a left paraclinoid aneurysm was detected by angiography.
Methods and Materials: A left pterional approach was adopted, combined with exposing the internal carotid artery at the cervical level, and an arciform durotomy with the opening of the sylvian fissure to the carotid cistern. The anterior clinoid process was exposed, revealing the aneurysm originating from the clinoid segment of the carotid artery; consequently, clipping was impossible without an anterior clinoidectomy. The dura was cut medially from the optic canal to the clinoid process. Drilling was performed at the base of the clinoid process to expose the distal carotid dural ring. The carotid was released in the clinoid segment by sectioning the distal dural ring to mobilize it. After identifying the distal and proximal neck of the aneurysm, reconstruction was initiated by placing a 90-degree clip in the anteroposterior direction; then, a second clip in the posteroanterior direction and puncturing the aneurysm, demonstrating that aneurysmal flow was present. Third and fourth clips were placed in tandem, one proximal to the internal carotid and the other at the dome of the aneurysm. Finally, a fifth curved clip was placed over the previous clips to increase their closure pressure.
Results: Postoperative angiography revealed complete exclusion of the aneurysm with adequate carotid permeability. The postoperative period lacked any complications or neurological deficits. The patient consented to have her images and videos published.
Conclusions: Combining a left pterional approach with exposing the internal carotid artery at the cervical level and performing an arciform durotomy at the sylvian fissure’s opening into the carotid cistern, an angiographically-detected left paraclinoid aneurysm was treated successfully with an excellent outcome.

Key words: Paraclinoid Aneurysm; Skull Base; Intradural Clinoidectomy; Tandem Clipping

BIBLIOGRAFÍA

1. Wei Zhu, Ying Mao “Anterior Clinoidectomy in Skull Base Technique” Department of Neurosurgery, Huashan Hospital of Fudan University, Shanghai Neurosurgical Center, Shanghai, People's Republic of China. World Neurosurgery, Volume 77, Issues 3-4, Pages 443-444.
2. Caramanti, R. L., da Costa, M. D. S., Hernández, Y. A. U., Alves Filho, C. A. F., Wainberg, R., Palmiero, H., Chaddad-Neto, F. (2017). Intradural Anterior Clinoidectomy for Ophthalmic Artery Aneurysm Clipping: 3-Dimensional Operative Video. Operative Neurosurgery, 14(6), 708–708.