Commentary

The authors present a nice series of 51 patients treated for large or giant paraclinoid aneurysms. All 51 patients underwent some form of surgical treatment, including proximal ligation in 1, bypass and trapping in 7, and direct clipping in 43. The management algorithm presented by the authors offers a very rational treatment strategy. This study is biased toward surgical intervention, and the bias is recognized by the authors. I agree with surgical intervention by direct clipping as the optimal treatment in most cases of symptomatic giant proximal carotid artery aneurysms. In my experience, these aneurysms invariably have very broad-based necks that essentially require “vascular reconstruction” rather than technical aneurysm clip application. The size of (or lack of a definable) neck is the reason that endovascular obliteration of theses aneurysms is often extremely difficult and often necessitates use of stent/coil combinations. I have also found that often the sheer volume of giant paraclinoid aneurysms will mandate insertion of a great number of coils to fill the aneurysm, making endovascular treatment exceedingly expensive in many circumstances. I have also seen better symptom resolution with surgical clipping because of the ability to decompress the aneurysm after clipping, which does not occur with endovascular therapy and a large deposit of an intraaneurysmal mass of coils.

Several words of caution should be mentioned when considering surgical treatment of these formidable lesions. First, retrograde suction decompression is not always completely reliable. When retrograde suction is applied to the cervical internal carotid artery, the arterial wall can collapse and prevent any significant aneurysm decompression. The surgeon should be immediately ready to puncture the aneurysm for direct decompression of the aneurysm dome rather than waste valuable time under temporary occlusion struggling with retrograde aspiration that is marginal or failing. I have also seen catastrophic traumatic carotid dissections created with repeated attempts to retrograde aspirate giant paraclinoid aneurysms during surgical clipping. Second, a surgeon must be very comfortable and facile with the anatomy and removal of the optic strut, which is the key to proximal exposure of the aneurysm neck in these cases. Third, I agree with the consideration of large-volume bypass in the cases where loss of the carotid artery is considered. I have seen delayed hemodynamic failure of small volume bypasses that remain patent but fail to supply the requisite replacement of the entire carotid blood flow.

The authors have demonstrated that there is a clear role for skilled microsurgeons when dealing with these difficult aneurysms.