Evolving Trends in the Management of Paraclinoid Aneurysms: A Review of the Literature and Examination of a Current Dual-Trained Practice

Introduction: Paraclinoid aneurysms arise from the internal carotid artery between the distal dural ring and the posterior communicating artery. The sensitivity of current imaging modalities has increased the number of paraclinoid aneurysms diagnosed. Prior to endovascular therapy, these aneurysms were treated with advanced microsurgical and skull base techniques. Endovascular flow diversion has revolutionized their management and increased the number of these lesions undergoing treatment.

Objective: Identify the evolving trends in the management of paraclinoid aneurysms through a review of the literature and examination of a current dual-trained practice.

Methods: A retrospective review of the literature was performed to analyze the incidence of paraclinoid aneurysms. We have also reviewed the senior author’s experience with paraclinoid aneurysms over the last year.

Results: A total of 6,601, both ruptured and unruptured, aneurysms were included in the review. Data analysis revealed that paraclinoid aneurysms constitute 29.5% of all aneurysms. Our retrospective one-year review of the senior authors case log identified that 38% of aneurysms treated were paraclinoid aneurysms. All of these paraclinoid aneurysms were unruptured and treated with flow diversion. At six months post treatment, 75% were obliterated and 25% were partially thrombosed.

Fig. 1: Right paraclinoid aneurysm treated with flow diversion. Right image is pre-treatment. Left image immediately posttreatment shows the flow diverting stent deployed across the aneurysm. There is significant stasis of contrast within the aneurysm.

Fig. 2 Paraclinoid aneurysm treated with flow diversion with occlusion at 6 months follow up.

Fig. 3 Left Ophthalmic aneurysm (Left) treated with flow diversion. Six month follow-up angiogram on Right showing complete obliteration of aneurysm.

Fig. 4 Bilateral paraclinoid aneurysms occluded at 6 months post flow diversion.

Conclusion: Paraclinoid aneurysms are among the most common intracranial aneurysms. Modern imaging has made it easier to diagnose these aneurysms. These lesions are challenging to manage due to their questionable intradural location, often small size and perceived low risk of rupture, and historically challenging microsurgical management. Flow diversion, which is minimally invasive, associated with a low incidence of morbidity, and high rate of durable obliteration, has increased the number of these lesions being treated. Future studies are needed to re-define decision-making and risk-benefit analyses, as imaging and intervention continue to evolve.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024