Background: While most paraclinoid aneurysms can be clipped with excellent results, new visual deficits postoperatively are a concern. Meanwhile, new technology like flow diverters has increased the popularity of endovascular therapy. However, endovascular treatment of paraclinoid aneurysms is not without procedural risks, is associated with higher rates of incomplete aneurysm occlusion and recurrence, and may not address optic nerve compression symptoms that surgical debulking can.
Objective: The increasingly endovascular management of paraclinoid aneurysms should be justified by comparisons to surgical benchmarks. Therefore, we aimed to define patient, visual, and aneurysm outcomes in the most common paraclinoid aneurysm: ophthalmic artery (OphA) aneurysms.
Methods: Results from microsurgical clipping of 208 OphA aneurysms in 198 patients were retrospectively reviewed. Patient demographics, aneurysm morphology (size, calcification, etc), clinical characteristics and patient outcomes were recorded and analyzed.
Results: Despite 20% of these aneurysms being large or giant in size, complete aneurysm occlusion was accomplished in 91% of aneurysms, with patency of OphA preserved in 99.5%. Aneurysm recurrence rate was 3.1% and retreatment rate was 0%. Good outcomes (modified Rankin Scale score: 0-2) were observed in 96.2% of patients overall, and in all 156 patients with unruptured aneurysms. New visual field defects (hemianopsia or quadrantanopsia) were observed in 3.8% (8 patients), decreased visual acuity in 2.4% (5 patients), and monocular blindness in 4.3% (9 patients). Vision improved in 9 of 17 patients (52.9%) with preoperative deficits.
Conclusion: The most important risk associated with clipping OphA aneurysms is a new visual deficit. Meticulous microsurgical technique is necessary during anterior clinoidectomy, aneurysm dissection, and clip application to optimize visual outcomes. As the results of endovascular therapy and specifically flow diverters become known, they warrant comparison with these surgical benchmarks to determine best practices.