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Paraclinoid Carotid Artery Aneurysms
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Indications for Craniotomy
Ruptured Aneurysm
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All paraclinoid aneurysms presenting with subarachnoid hemorrhage that are unfavorable for endovascular treatment.
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Paraclinoid ruptured aneurysms with Hunt and Hess grade I, II, or III presentation and age 50 years or younger.
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Multiple or bilateral paraclinoid aneurysms, one of which is unfavorable for endovascular treatment in the setting of uncertainty regarding the source of rupture.
Symptomatic Unruptured Aneurysm
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Generally, large or giant aneurysms are symptomatic from mass effect. Because of close proximity to anterior optic pathways, these aneurysms may cause visual disturbances as presenting symptoms. These cases should be treated to prevent further visual loss or for improvement of vision.
Asymptomatic Unruptured Aneurysm
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Patients younger than 60 years old with aneurysms larger than 5 mm that are unfavorable for endovascular treatment should be offered surgery.
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Large, incidental aneurysms greater than 10 mm that are unfavorable for endovascular treatment should considered for surgery.
Contraindications
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Aneurysms that are large or giant, have a calcified neck, or have an ill-defined neck are difficult to clip and may require carotid occlusion +/- bypass as a definitive treatment.
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Other relative contraindications for definitive surgical clipping are patient factors such as advanced age and serious comorbidities.
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