Endoscopic Endonasal Aneurysm Clipping

Introduction: Modern innovations in vascular neurosurgery have allowed for safer and less invasive approaches to treat a wide range of pathologies. Intracranial aneurysms are formidable lesions with high morbidity and mortality rates associated with rupture. While endovascular approaches have significantly improved in the past decade, there are still indications for aneurysm clipping. The endoscopic endonasal approach (EEA) gives access to the skull base and its cisterns. In this paper, we review the use of the EEA for aneurysm clipping.

Methods: A systematic review was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Specific terms such as “endoscopic endonasal” and “aneurysm” were used to search three independent databases. Inclusion and exclusion criteria were set, and the extracted literature was reviewed in two phases by two independent reviewers to include only papers that discussed the use of EEA for aneurysmal clipping. Extracted data included age, gender, history, location of the aneurysm, approach, and reason for approach with preoperative and postoperative assessments.

Results: A total of 930 papers were reviewed. Fifteen papers met the inclusion criteria with a total of 31 patients reported. Mean age was 51.61 years (range = 28–74 years). Presenting symptoms included headaches (35.5%), gait disturbances (12.9%), loss of consciousness (12.9%), and cranial nerve palsy (12.9%). The total number of clipped aneurysms clipped was 42. The most common location of these aneurysms was the anterior communicating artery (n = 8), the carotid ophthalmic segment (n = 8), and the basilar artery (n = 7), paraclinoid carotid segment (n = 6). Seven were ruptured aneurysms. Various approaches were used depending on aneurysm location. These include extended endonasal, transclival, transsphenoidal, transplanum, transplanum–transtuberculum, and transsellar–transplanum. The mean follow-up was 8.6 months. Thirty aneurysms did not have occlusion outcomes reported. Eleven aneurysms where completed occluded and one had a residual neck. Postoperatively, complications included ischemic strokes (n = 5), CSF leak (n = 4), cranial nerve palsies (n = 2), weakness (n = 2), pneumonia pulmonary embolism (n = 2), and four patients had CSF leak.

Conclusion: The literature on EEA for aneurysm clipping is scarce. CSF leaks and proximal control remain the main limitations. The development of 3D endoscopes, better dural closure techniques, and increase in experience and familiarity with the endoscope are the next necessary steps before the adoption of EEA as an approach for aneurysm clipping. However, at this time, treatment recommendations based on this approach is premature.