Surgical Management of Ophthalmic Segment Aneurysms: Experience at Army Hospital (Research & Referral), New Delhi

Aims and Objectives: To analyze the results of surgical management by clipping in cases of ophthalmic segment aneurysms operated on over the last 3 years at Army Hospital (R&R), New Delhi—the apex referral center for the Armed Forces.

Materials and Methods: All cases with four-vessel cerebral DSA-proven ophthalmic segment aneurysms between July 2009 and June 2012 were included. All cases were operated on through a pterional craniotomy after securing proximal access of the ICA in the neck. The anterior clinoid process (ACP) was drilled intradurally. Surgical technique and outcome were reviewed.

Results and Discussion: There were a total of 19 aneurysms in 14 female and 5 male patients. Age range was 40 to 70 years. Time of admission from time of ictus was less than 24 hours in one patient, 1-3 days in six patients, 3-10 days in six patients, and more than 10 days in four patients.. Hunt and Hess grades were: grade 1 in four patients, grade 2 in six, and grade 3 in nine. Size of aneurysms varied from 3-5 mm (in 2 patients), 05-10 mm (12), and more than 10 mm (5). Six patients had associated multiple aneurysms. Intraoperatively, these aneurysms can be a tricky proposition due to their intimate relationship with the anterior clinoid process. Only when drilled optimally, with the dural ring released to identify the proximal aspect of the aneurysm neck, can they be successfully clipped. There was intraoperative rupture in three cases. Postoperatively, three patients developed hemiparesis, from which they recovered; one patient had meningitis; one had transient diplopia and recovered; and three patients developed chest-related complications. There were two deaths. Follow-up has ranged from 2 months to 3 years. Glasgow outcome scores were: GOS 1 in 2 patients, GOS 2 in 1, GOS 3 in 1, GOS 4 in 3, and GOS 5 in 12. Overall, 79% of patients had good outcome (GOS 4 or 5).

Conclusions: Opthalmic segment aneurysms are challenging to manage due to their proximity to the skull base and the visual apparatus and difficulty in securing proximal control intracranially. This notwithstanding, they can be successfully clipped if the intimate anatomical relationships of the aneurysms with the optic nerve, ACP, optic strut, and the dural ring are defined properly during surgery. Optimal drilling of the ACP is a key element to successful outcome.