Neurol India Close
 

Figure 6: Case 2: (a) T2-weighted MR image showed bilateral 'kissing' aneurysms of the ICA located in the suprasellar cistern. (b) Basal CT angiogram showing bilateral, medially-directed 'kissing' superior hypophyseal aneurysms with the left-sided aneurysm being larger than the right-sided one. (c-g) Schematic illustrations of the surgical technique. (c) Using a left-sided fronto-temporal trans-Sylvian approach, the left internal carotid artery (ICA), anterior cerebral artery (ACA) and middle cerebral artery (MCA) are exposed. The left-sided superior hypophyseal artery aneurysm (*1) is arising from the ICA, has a broad neck and is pointing medially towards the suprasellar cistern, elevating the left optic nerve. The right-sided superior hypophyseal artery aneurysm (*2) is also pointing medially and is smaller than its counterpart on the left side. The proximal portion of the neck of both the aneurysms is covered by the optic nerve (II), planum sphenoidale (PS) and anterior clinoid process (ACP), on either side, respectively. The fundi of the two aneurysms (mirror aneurysms) are touching each other in the suprasellar cisterns; (d) The part of planum sphenoidale (PS) forming the roof of optic foramen as well as the left anterior clinoid process (ACP) are drilled, exposing the part of the optic nerve within the optic foramen (covered by falciform ligament; exposed optic nerve: E II) and the clinoidal segment of ICA (proximal internal carotid artery: P ICA), respectively (#: Exposed and drilled part of PS). (e) The broken lines and arrow indicate the dural incision over the planum sphenoidale and ACP to access the proximal portion of neck of the right-sided aneurysm. (f) Three fenestrated clips (taking the ICA in the fenestration) are applied to occlude the lumen of the left-sided aneurysm. The superior blades of the three clips traverse the optico-carotid plane below the left optic nerve. On the left side, working from the right side, the part of planum sphenoidale (PS) forming the roof of optic foramen as well as the left anterior clinoid process (ACP) are drilled exposing the part of the right optic nerve within the optic foramen (curved arrow). (g) The right-sided ICA (arrow) and the aneurysm (*2) are visible below the right optic nerve. Two straight clips are also applied to the neck of the right-sided aneurysm

Figure 6: Case 2: (a) T2-weighted MR image showed bilateral 'kissing' aneurysms of the ICA located in the suprasellar cistern. (b) Basal CT angiogram showing bilateral, medially-directed 'kissing' superior hypophyseal aneurysms with the left-sided aneurysm being larger than the right-sided one. (c-g) Schematic illustrations of the surgical technique. (c) Using a left-sided fronto-temporal trans-Sylvian approach, the left internal carotid artery (ICA), anterior cerebral artery (ACA) and middle cerebral artery (MCA) are exposed. The left-sided superior hypophyseal artery aneurysm (*1) is arising from the ICA, has a broad neck and is pointing medially towards the suprasellar cistern, elevating the left optic nerve. The right-sided superior hypophyseal artery aneurysm (*2) is also pointing medially and is smaller than its counterpart on the left side. The proximal portion of the neck of both the aneurysms is covered by the optic nerve (II), planum sphenoidale (PS) and anterior clinoid process (ACP), on either side, respectively. The fundi of the two aneurysms (mirror aneurysms) are touching each other in the suprasellar cisterns; (d) The part of planum sphenoidale (PS) forming the roof of optic foramen as well as the left anterior clinoid process (ACP) are drilled, exposing the part of the optic nerve within the optic foramen (covered by falciform ligament; exposed optic nerve: E II) and the clinoidal segment of ICA (proximal internal carotid artery: P ICA), respectively (#: Exposed and drilled part of PS). (e) The broken lines and arrow indicate the dural incision over the planum sphenoidale and ACP to access the proximal portion of neck of the right-sided aneurysm. (f) Three fenestrated clips (taking the ICA in the fenestration) are applied to occlude the lumen of the left-sided aneurysm. The superior blades of the three clips traverse the optico-carotid plane below the left optic nerve. On the left side, working from the right side, the part of planum sphenoidale (PS) forming the roof of optic foramen as well as the left anterior clinoid process (ACP) are drilled exposing the part of the right optic nerve within the optic foramen (curved arrow). (g) The right-sided ICA (arrow) and the aneurysm (*2) are visible below the right optic nerve. Two straight clips are also applied to the neck of the right-sided aneurysm