Editorial: Ophthalmic segment aneurysms

Very large and giant paraclinoid aneurysms are a therapeutic challenge. The goal of treatment is prevention of aneurysm growth/rupture and, in those patients with visual symptoms related to mass effect, stabilization and possible improvement of the visual deficits. Better understanding of the 3D relationships of the anterior clinoid/optic nerve/aneurysm–internal carotid artery (ICA) complex has resulted in good surgical outcomes being reported in several series. Traditional endovascular methods (coiling with or without the adjunct of balloon and stent assistance) provide an effective treatment for most small paraclinoid aneurysms with a very low complication rate.1 However, until the development of flow diverters, ICA-preserving endovascular solutions for very large and giant aneurysms were less than ideal with a very high recurrence rate. Carotid sacrifice is a valid option in many patients with very large and giant paraclinoid aneurysms, but concerns exist about the development of flow-related aneurysms and long-term effects. In their article, Mattingly and coworkers4 detail visual and clinical outcomes in a series of 17 patients (with clipped aneurysms) with challenging ophthalmic segment aneurysms. This report is an honest assessment of the results that particularly pertain to visual symptoms. Of the 14 patients presenting with visual symptoms, 79% experienced improvement in their vision at follow-up, while 21% experienced worsening in the ipsilateral eye. When visual acuity is considered, 53% of patients improved and 16% worsened. The authors used a modification of the suction-decompression technique and do a nice job in discussing the technical nuances. The value of this detailed study is to provide a benchmark (especially in relation to visual outcome) against which results of modern series can be evaluated. This is of special importance at a time when the development of flow diverters may represent a major paradigm shift and may soon become the treatment of choice for these challenging lesions.3,5 In the Pipeline for Uncoilable or Failed Aneurysms (PUFS) study, a detailed preand postoperative neuroophthalmological assessment was part of the study protocol. In the PUFS study, 17 patients had optic neuropathy (defined as a visual field deficit, decreased visual acuity, or an afferent pupillary defect) related to the aneurysm. Six months after treatment, 53% of the patients experienced improvement of their visual symptoms, 41% were stable, and only 1 patient (6%) experienced worsening.2 Thus, although not as good as the results reported in this series, it appears that visual outcomes after flow diversion are fairly close. (http://thejns.org/doi/abs/10.3171/2012.12.JNS121401)