J Neurosurg 62:667-672, 1985

A combined epi- and subdural direct approach to

carotid-ophthalmic artery aneurysms

VINI<O V. DOLENC, M.D., D.Sc.

University Department of Neurosurgery, UniversityMedical Center, Ljubljana, Yugoslavia

v- A series of 14 patients with a carotid-ophthalmic artery aneurysm were treated operatively. In five patients
the aneurysms were large, but only one of these had ruptured; four of these patients had symptoms of mass
lesions. The remaining nine patients were operated on for a ruptured aneurysm; seven had subarachnoid
hemorrhage due to the carotid-ophthalmic artery aneurysm and two had bleeding from another aneurysm in
the presence of an asymptomatic carotid-ophthalmic artery aneurysm. All patients were treated by a combined
epi- and subdural direct surgical approach, which excluded the carotid-ophthalmic artery aneurysm from the
circulation and made possible the preservation of the adjacent structures. Two patients died: one a few hours
after surgery from a massive thromboembolism of the pulmonary artery and another 2 months after surgery
as a result of gastrointestinal bleeding. All the other patients showed postoperative improvement in symptoms
and signs. This report focuses on a modified direct surgical approach involving exposure of the internal carotid
artery proximal to the lesion, and of the ophthalmic artery, which is of primary importance in securing safe
and complete occlusion of a carotid-ophthalmic artery aneurysm. Removal of individual bone structures at
the base of the skull provides a better and safer exposure of the central segment of the internal carotid artery
than does excessive and hazardous retraction of the brain.

KEY WORDS ~ carotid artery 9 ophthalmic artery 9 aneurysm 9 surgical technique

A
NEURVSMSarising from the internal carotid artery
(ICA) .between the.ophthalmic artery and the
postenor c o m m u m c a t m g artery, at any point
of the circumference, are referred to as carotid-oph-
thalmic artery a n e u r y s m s . 6-8"l~ Aneurysms occur-
ring on this segment of the ICA are u n c o m m o n and
account for only 5% of all intracranial aneurysms. 3'~2
The majority of these aneurysms arise from the medial
half of the ICA circumference, close to the ophthalmic
artery. They are frequently large or giant in size.
The following classification of carotid-ophthalmic
artery aneurysms according to location has been pro-
posed by several authors and is used here: suboptochias-
mal, latero-optochiasmal, suprachiasmal, global, and
partially intracavernous. This classification has proved
of great practical value, especially in the management
of large and giant aneurysms. Of primary importance
is the relationship of the aneurysm to its neighboring
structures: the optic nerve, chiasm, pituitary stalk, hy-
pothalamus, 1CA, third cranial nerve, cavernous sinus,
and bone structures.
Symptoms and signs produced by large and giant
aneurysms at this site are more often caused by com-
pression of the adjacent structures than by subarach-
noid hemorrhage (SAH), yet the potential for rupture
cannot be ruled out. On the other hand, small carotid-
ophthalmic artery aneurysms frequently rupture, with
a resulting SAH. Bilateral carotid-ophthalmic artery
aneurysms, associated either with multiple aneurysms
at other sites or with arteriovenous malformations
(AVM's), have been reported. 1'9'I3'19 A preponderance
in female patients and a left-sided predominance of
carotid-ophthalmic artery aneurysms have been re-
ported. 8'~4 The number of cases of carotid-ophthalmic
artery aneurysms reported in the literature is very small
as compared to the number of other intracranial aneu-
rysms.
Many authors agree that the management of carotid-
ophthalmic artery aneurysms is more demanding and
is associated with higher risks and hazards than the
operative treatment of other aneurysms. It is sometimes
difficult or even impossible to determine angiographi-
cally the exact point of origin of a carotid-ophthalmic
artery aneurysm, especially a large one. Preoperative
four-vessel angiography, thorough cross-flow studies,
and an accurate estimate of the functional relationship
between the vertebral and carotid systems are impera-
tive. In certain situations, some authors prefer indirect

J. Ak'urosurg. / Volume 62/ May, 1985 667


treatment by ligation of the common carotid artery to
a direct surgical approach. In some cases, partial re-
moval of the anterior clinoid process, partial resection
of the optic nerve, and unroofing of the optic canal,
alone or in combination, provided visualization of the
ophthalmic artery and the aneurysm. 3,5,8,9'13'19A contra-
lateral approach to carotid-ophthalmic artery aneu-
rysms has been regarded as the method of choice. ~3 In
the treatment of bilateral carotid-ophthalmic artery an-
eurysms, both a direct and a contralateral approach
have been employed. 1149
Since surgical treatment of carotid-ophthalmic artery
aneurysms has proved rather difficult and the results
less than gratifying, opinions differ as to the best method
of treatment. This has resulted in a variety of techniques
being proposed. A description of a combined epi- and
subdural surgical approach to these aneurysms is given
here, and a summary of 14 cases treated with this
technique is presented.
Surgical Technique
A standard pterional approach was used in all 14
cases. ~8 In this procedure, the placement and fixation
of the patient's head and the tilting of the operating
table during surgery are calculated to position the distal
intracavernous segment of the ICA horizontally, and
the superior orbital fissure vertically. After craniotomy,
the dura is separated from the orbital roof medially and
laterally to the superior orbital fissure. The roof of the
orbit is removed from the orbital edge along with the
sphenoid wing backward to the anterior clinoid, and to
the entrance to the optic canal from the orbital aspect.
A partial removal of the lateral orbital wall between the
superior orbital fissure and the foramen rotundum is
then carried out. Utmost care is taken not to damage
the orbital periosteum and to detach it safely from the
bone. The dura is manipulated in the same manner. At
this stage, the superior orbital fissure and the structures
under the vertical roof of the dura mater appear in the
center of the operating field.
The foramen rotundum is located laterally, and the
anterior clinoid, connected with the roof of the optic
canal through its lateral wall, is situated medially. At
the rear, facing the surgeon, the dura mater is seen
under the frontal lobe medially, while the dura in front
of the temporal lobe is situated laterally with the intraor-
bital structures in front (Fig. 1). With a diamond drill
and under continuous irrigation and suction, a portion
of the anterior clinoid is drilled off medially, and sepa-
rated from the lateral wall of the optic canal. In this
manner, the anterior clinoid is detached from the ad-
jacent bone structures, but not from the dura mater
overlying the distal and medial portions of the cavern-
ous sinus and the ICA inside the cavernous sinus. Then
the central part of the anterior clinoid is drilled, and
blunt dissection of the thinned walls from the dura is
carried out with a dissector (Fig. 1). A complete extir-
pation of the anterior clinoid is accomplished. In the
668
V. V. Dolenc
FIG. 1. Intraoperative view of the left pterional region
following craniotomy, orbitotomy, removal of the sphenoid
wing with the anterior clinoid, and unroofing of the optic
canal. The superior orbital fissure structures are covered with
dura. Note the orbital globe in front, the dura over the frontal
lobe on the right, and the dura over the pole of the temporal
lobe on the left. The broken line indicates the incision of the
dura.
event of damage to the cavernous sinus wall, venous
bleeding can be readily controlled by packing the cav-
ernous sinus with Surgicel. The removal of the anterior
clinoid exposes the horizontally situated intracavernous
segment of the ICA, which in a normal upright position
passes vertically along the lateral border of the anterior
sella turcica wall and enters the intradural space, giving
origin to the ophthalmic artery.
A normal anterior clinoid is firm and solid and rarely
contains air. With aneurysms extending into the cav-
ernous sinus or over the anterior clinoid, the anterior
clinoid may be very thin or even absent. In such cases,
removal of the medial portion of the sphenoid wing
requires great caution. The proximal wall or, at least, a
part of the lateral wall of the optic canal should be
removed with a diamond microdrill. Unroofing is car-
ried out meticulously in order not to damage the oph-
thalmic artery and/or the optic nerve. Continuous irri-
gation of the drill is imperative in order to prevent
thermal damage to the optic nerve. After the optic canal
has been unroofed from the proximal aspect, the medial
wall is drilled off with utmost care so as not to open the
ethmoid sinus or damage its dorsal cells. Accidental
opening of the ethmoid sinus is often difficult to avoid
if the cavity extends far laterally. In these cases, our
policy is to leave intact at least the mucous membrane
of the sinus or to close the opening with bone wax.
Usually, the entire optic nerve inside the optic canal
can be exposed before opening the dura mater. In rare
cases in which a giant carotid-ophthalmic artery aneu-
rysm extends over the anterior clinoid into the anterior
cranial fossa or into the cavernous sinus, complete
unroofing of the optic canal should not be attempted
without opening the dura. Good extra- and intradural
visualization of the optic nerve is mandatory for a safe
unroofing of the dorsal segment of the optic canal.
In most cases, incision of the dura is made after the
J. Neurosurg. / Volume 62 / May, 1985
Carotid-ophthalmic artery aneurysm surgery
FIG. 2. Intraoperative view following dural incision. The
intra- and extradural segments of the optic nerve are visualized
as well as the carotid-ophthalmic artery aneurysm, the oph-
thalmic artery, and the internal carotid artery, proximal to the
ophthalmic artery (in the cavernous sinus) and distal to the
lesion. Cranial nerves III and IV are dissected in the superior
orbital fissure as they run forward to the eye. Arrow indicate
possible locations for placement of temporary clips on the
internal carotid artery.
anterior clinoid has been completely extirpated and the
optic canal unroofed in its entire length from the lateral,
medial, and proximal aspects, thus providing latero-
medial mobility of the optic nerve inside the dura
propria. The incision is made longitudinally to the
Sylvian fissure, and is continued medially to the dura
mater passing through the superior orbital fissure, to
the original site of the anterior clinoid. The incision of
the dura is then continued transversely and medially
over the ICA and the optic nerve, leaving a 2- to 3-mm
border at the base. This provides good visualization of
the optic nerve inside the optic canal, both extradurally
and intradurally, and the ICA can also be seen intra-
durally. Then the incision is extended perpendicular to
the previous transverse incision line at the base, along
the lateral border of the optic nerve, and is continued
at least halfway along the optic canal. This longitudinal
incision allows exposure of the optic nerve in the optic
canal inside the dura propria, and, by displacing the
nerve medially, the ophthalmic artery is visualized on
the lateral aspect under it. The dural incision is also
made along the ICA in order to expose its distal segment
in the cavernous sinus (Fig. 1).
Venous bleeding is controlled by packing the cavern-
ous sinus around the vessel with Surgicel. This affords
visualization of the intracavernous segment of the ICA,
at least 3 to 4 mm in length, proximal to the point of
origin of the ophthalmic artery (Fig. 2). The exposed
segment of the ICA inside the cavernous sinus should
be sufficient to allow for temporary or permanent clip-
ping. After exposing the ophthalmic artery and an
adequately large segment of the ICA in front of it, and
ascertaining that the placement of a temporary clip
proximal to the ophthalmic artery will provide a safe
interruption of the blood flow, the intradural part of
J. Neurosurg. / Volume 6 2 / May, 1985
the operation is started. The manipulation of a large
carotid-ophthalmic artery aneurysm can only begin
after it is ascertained that a temporary clip can be placed
on the distal part of the ICA, peripherally, before the
point of origin of the anterior cerebral artery and the
middle cerebral artery, or on these two vessels, and also
on the posterior communicating artery. When it is
certain that clipping can be accomplished without com-
promising the optic nerve, the chiasm, or the third
cranial nerve, one or two clips are applied to the carotid-
ophthalmic artery aneurysm. If the wall of the aneurys-
mal neck is too thick, if the aneurysm contains a
thrombus, or if the position of the aneurysm prevents
complete occlusion, clipping will be inadequate; in such
cases the aneurysm is occluded by placing temporary
clips proximally and distally on the ICA or its branches.
The aneurysm is then opened, emptied, or resected,
and clipped. In cases of carotid-ophthalmic artery an-
eurysms not amenable to clipping, the ICA wall is
reconstructed by interrupted sutures. The reconstructed
vessel is wrapped in muslin and fastened with a clip. If
a thrombus is found in the carotid-ophthalmic artery
aneurysm, it is evacuated without attempting to detach
the aneurysmal sac from the chiasm or the medial
structures of the upper brain stem.
Vessels originating from the ICA and passing to the
optic nerve and the chiasm should be spared whenever
possible. 4 After exclusion of the aneurysm from the
circulation, the dura is closed. In cases where the dura
at the base of the skull cannot be closed in a watertight
manner, Surgicel is placed epidurally along the suture
line; however, the surgeon's objective should be to
accomplish a watertight closure, particularly when the
ethmoid sinus has been opened, in order to prevent
leakage of cerebrospinal fluid.
The operation is terminated according to routine
procedure. No special measures, such as hypotension,
dehydration, hypothermia, or lumbar drainage, are
taken during surgery. Blood transfusion is required only
in the event of rupture of the carotid-ophthalmic artery
aneurysm during surgery, when it is not amenable to
timely occlusion by temporary clipping.
Summary of Cases
The clinical course of 14 patients treated for a carotid-
ophthalmic artery aneurysm is summarized in Table 1.
There were 11 women and three men. The carotid-
ophthalmic artery aneurysm was on the left side in nine
cases and on the fight in five. Five of the 14 patients
harbored large carotid-ophthalmic artery aneurysms,
and only one of these had ruptured (Fig. 3). Other large
aneurysms mimicked mass lesions by producing symp-
toms of compression of the adjacent structures. Nine
patients were initially examined because of SAH, which
in seven cases was due to a ruptured carotid-ophthalmic
artery aneurysm and in two cases was caused by an
associated aneurysm; a silent carotid-ophthalmic artery
669
 V. V. Dolenc

TABLE 1
Clinical summary of 14 cases of carotid-ophthalmic artery aneurysms*

Case Sex, Aneurysm Time Sur-

Age Location Clinical Preoperative Signs Surgical Neurological Status
Presentation & Symptoms Procedure~" gery to at Discharge
No. (yrs) CO Other Discharge
1 M, 38 rt SO -- SAH (CO) headache, stiffneck clipping 16 days normal
2 F, 49 It SO ACoA SAH (ACoA) rt-sided hemiplegia clipping of both 2 mos psycho-organic syn-
aneurysms drome, rt-sided hemi-
paresis
3 F, 51 it CO It MCA SAH (MCA) headache, stiff neck clipping of both 14 days normal
(lateral) aneurysms
4 F, 41 large rt -- SAH (CO) headache for many years, clipping 7 mos psycho-organic syn-
SO progressive deterioration of drome, rt optic atro-
vision in rt eye; paraparesis phy, paraparesis
1 year prior to SAH
5 F, 57 large It -- headache, progressive blindness, quadriparesis resection ofle- 2 mos death due to gastroin-
SO deterioration of vi- sion, recon- testinal bleeding (au-
sion; quadriparesis struction of ICA topsy)
6 F, 38 large rt -- headache, progressive headache, almost complete resection of le- 15 days normal; good recovery
SO deterioration of vision blindness in rt eye sion, clipping of vision in rt eye
7 M, 36 rt SO -- SAH (CO) headache, stiff neck clipping 11 days normal
8 F, 44 It SO -- SAH (CO) headache, stiff neck clipping 12 days normal
9 F, 58 large It -- headache, progressive headache for 20 years, al- application of 19 days normal; good recovery
SO deterioration of vision most complete blindness in two clips of vision in It eye
in It eye It eye
10 M, 36 rt SO -- SAH (CO) headache, stiff neck clipping 7 days normal
11 F, 54 It SO AVM SAH (CO) headache, stiff neck clipping 6 hrs sudden death after sur-
(It PCA) gery due to massive
thromboembolism (au-
topsy)
12 F, 49 It SO ACoA SAH (CO) headache, stiff neck clipping 8 days normal
13 F, 68 It global, -- SAH (CO) headache for many years, resection of le- 16 days normal; good recovery
partially deterioration of vision in It sion, recon- of vision in It eye
intracav- eye struction of ICA
ernous
14 F, 60 rt global -- SAH (CO) headache for many years, clipping 19 days normal; good recovery
deterioration of vision in rt of vision in rt eye
eye
* Abbreviations: SO = suboptochiasmal location; CO = carotid-ophthalmic artery aneurysm; ACoA = anterior comunicating artery; MCA =
middle cerebral artery; ICA = internal carotid artery; PCA = posterior cerebral artery; SAH = subarachnoid hemorrhage; AVM = arteriovenous
information.
t Ya~argil clips were used for clipping in all cases except Case 9, in which Sugita clips were used.

a n e u r y s m was associated w i t h a n e u r y s m s at o t h e r sites w h e n u n t r e a t e d t h e y are apt to r e b l e e d ? M o s t small

in three cases, a n d w i t h an A V M in o n e case.
O n e p a t i e n t (Case 5) d i e d f r o m gastrointestinal c o m -
p l i c a t i o n s 2 m o n t h s p o s t o p e r a t i v e l y , a n d a n o t h e r pa-
tient (Case 11) s u c c u m b e d to m a s s i v e p u l m o n a r y
t h r o m b o e m b o l i s m 2 h o u r s after surgery. Eight p a t i e n t s
m a d e a c o m p l e t e recovery, w h i l e three h a d visual s y m p -
t o m s in the ipsilateral eye w i t h g r a d u a l i m p r o v e m e n t
o f vision p o s t o p e r a t i v e l y . T w o p a t i e n t s w i t h p r e o p e r a -
tive m o t o r deficits a n d a p s y c h o - o r g a n i c s y n d r o m e
(Cases 2 a n d 4) s h o w e d i m p r o v e m e n t o f their s y m p t o m s
after the o p e r a t i o n .
Discussion
Small carotid-ophthalmic artery aneurysms are
a s y m p t o m a t i c unless t h e y r u p t u r e a n d cause an S A H ; ~2
c a r o t i d - o p h t h a l m i c artery a n e u r y s m s are d i s c o v e r e d
w h e n t h e y r u p t u r e a n d bleed.19 O n l y a s m a l l p r o p o r t i o n
are a s y m p t o m a t i c ; t h e y are d e t e c t e d i n c i d e n t a l l y be-
cause o f the r u p t u r e o f an a s s o c i a t e d a n e u r y s m . In s o m e
cases t h e first S A H is c a u s e d by a c o e x i s t i n g a n e u r y s m
arising at s o m e o t h e r site, a n d t h e s e c o n d bleed is d u e
to r u p t u r e o f a c a r o t i d - o p h t h a l m i c artery aneurysm.~L
A vast m a j o r i t y o f g i a n t c a r o t i d - o p h t h a l m i c artery
a n e u r y s m s p r o d u c e signs a n d s y m p t o m s o f c o m p r e s -
sion o f the a d j a c e n t structures, m o s t often o f the optic
n e r v e a n d c h i a s m . 1'7'8'12'14'1sA7-19 T h e f u n c t i o n o f the
p i t u i t a r y g l a n d is o n l y rarely c o m p r o m i s e d . 2 Surgical
m a n a g e m e n t o f a n e u r y s m s by c o m p l e t e e x c l u s i o n o f
the lesion f r o m the circulation, p r e s e r v i n g t h e p a t e n c y
o f the p a r e n t a n d d a u g h t e r arteries, is the o n l y m e t h o d

670 J. Neurosurg. / Volume 6 2 / May, 1985

Carotid-ophthalmic artery aneurysm surgery

F1G. 3. Right carotid angiograms, anteroposterior views (left) and lateral views (right). Upper:Preopera-
tive angiograms showing a large carotid-ophthalmic artery aneurysm (suboptochiasmal type) of the internal
carotid artery. This aneurysm had ruptured. Lower. Postoperative angiograms showing a clip on the carotid-
ophthalmic artery aneurysm. The ophthalmic artery can be seen proximal to the clip on the lateral view.

that provides definitive treatment of the aneurysm, This
applies also to the carotid-ophthalmic artery aneurysm,
where the operation often involves decompression of
adjacent structures compressed by a giant aneurysm.
The size and particular relationship with other struc-
tures of some carotid-ophthalmic artery aneurysms
make them highly dangerous targets for direct operative
treatment. Therefore, some authors advocate indirect
treatment by ligation of the common carotid artery in
t h e n e c k . 6"10"14"17Ligation of the c o m m o n carotid artery,
however, does not prevent recurrent hemorrhage. Fur-
thermore, this method of treatment does not relieve
compression by a thrombosed giant aneurysm.
We cannot support a "careful observation" policy,
not even in asymptomatic patients with a confirmed
carotid-ophthalmic artery aneurysm. Excellent results
have been achieved by direct approach and complete
exclusion of this type of aneurysm. 1,~6-~9None of our
patients showed visual impairment. This was due not
only to the gentle manipulation of the optic nerve but
also to the preserved ICA supply to the optic nerve and
chiasm. 4~ The combined epi- and subdural approach
to carotid-ophthalmic artery aneurysms described here
affords ample space for manipulation around the lesion,
requires minimal retraction of the brain, and is, there-
fore, much safer and less traumatic than are other
methods of treatment.
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Manuscript received July 30, 1984.
Accepted in final form December 6, 1984.
Address reprint requests to: Vinko V. Dolenc, M.D., D.Sc.,
Department of Neurosurgery, University Medical Center, Za-
16ska 7, 61105 Ljubljana, Yugoslavia.
J. Neurosurg. / Volume 6 2 / May, 1985