Commentary

The authors have presented their microneurosurgical experience in managing 51 consecutive patients with large or giant proximal carotid aneurysms managed for a 10-year period. These 51 patients had a number of complicating features of their aneurysms, increasing the complexity of surgical management. Complicating factors included presentation with subarachnoid hemorrhage in 73%, giant size in 53%, intraluminal thrombosis in 24%, and calcification of the aneurysm in 8%. Despite these confounding factors, the authors report very good results in their 6-month follow-up. Complications included death in 4%, visual loss, transient oculomotor palsy, stroke, and cerebrospinal fluid leakage. Overall, the results are quite impressive and are attributed to a number of surgical adjuncts used on a routine basis by the authors. Balloon test occlusion was performed in all patients, 14 of whom did not tolerate the temporary occlusion. Other surgical adjuncts include routine exposure of the cervical carotid artery for proximal exposure and complete removal of the anterior clinoid process with opening of the dural ring, if necessary. Once the aneurysm is exposed, the authors liberally used retrograde suction to collapse the aneurysm and monitored patients with intraoperative EEG and SSEP monitoring. Intraoperative imaging was enhanced by the use of the endoscope in selected cases, microvascular Doppler ultrasonography, and more recently, ICG videoangiography. In 14% of the patients the operation included an extracranial/intracranial bypass with trapping of the aneurysm.

The authors clearly state their preference for microsurgical treatment of large and giant aneurysms in the paraclinoid region. Their more limited use of endovascular therapy is justified by the greater durability of microsurgical treatment of these lesions, the greater ability to eliminate associated mass effect, and the increased costs of endovascular therapy in their country of China.