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Background: Clipping continues to be one of the treatment strategies for ophthalmic artery aneurysms not amenable for stenting or coiling, or when long-term treatment durability is a concern. However, crescent development of endovascular techniques demands minimal invasiveness in the transcranial approaches while ensuring satisfactory results., Methods: We describe an extradural micropterional keyhole approach (eMKA) to the paraclinoid region and highlight the key anatomical elements of this surgical approach., Conclusion: The eMKA is a minimally invasive approach that provides access to the paraclinoid region using an extradural corridor. Therefore, it is suitable for clipping of ophthalmic artery aneurysms and other paraclinoid aneurysms.

Background: Several diseases that involve the optic canal or its contained structures may cause visual impairment. Several techniques have been developed to decompress the optic nerve., Objective: To describe minimally invasive extradural anterior clinoidectomy (MiniEx) for optic nerve decompression, detail its surgical anatomy, present clinical cases, and established a proof of concept., Methods: Anatomic dissections were performed in cadaver heads to show the surgical anatomy and to show stepwise the MiniEx approach. In addition, these surgical concepts were applied to decompress the optic nerve in 6 clinical cases., Results: The MiniEx approach allowed the extradural anterior clinoidectomy and a nearly 270° optic nerve decompression using the no-drill technique. In the MiniEx approach, the skin incision, dissection of the temporal muscle, and craniotomy were smaller and provided the same extent of exposure of the optic nerve, anterior clinoid process, and superior orbital fissure as that usually provided by standard techniques. All patients who underwent operation with this technique had improved visual status., Conclusions: The MiniEx approach is an excellent alternative to traditional approaches for extradural anterior clinoidectomy and optic nerve decompression. It may be used as a part of more complex surgery or as a single surgical procedure., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Our objective is to present and asses the utility of three-dimensional (3D) intraoperative imaging as a teaching method for anterior circulation aneurysm surgery., Methods: The senior author's experience in anterior circulation aneurysm surgery during a 28-month period was documented and processed as 3D images and compared with two-dimensional (2D) images. Both 2D and 3D sets of images were created, and, along with a specially designed questionnaire, 30 physicians (15 experienced cerebrovascular surgeons and 15 neurosurgical trainees) were asked to answer the query and state the advantages and disadvantages of both methods., Results: All physicians interviewed agreed that 3D imaging was better than 2D imaging, and that depth perception improved understanding of surgical tactics and anatomical landmarks. The resident/young trainee group seemed to receive more benefit from this than the experienced group. A total of 40% of residents and 20% of the experienced surgeons acknowledged a change in clipping strategy when comparing both sets. 3D imaging improved understanding of the ophthalmic segment in 66.6% of residents and 33.3% of the experienced group., Conclusion: Real 3D imaging in anterior circulation aneurysm surgery is an excellent tool to enhance vascular training. Inexperienced trainees seem to benefit greatly from it. This technique might be of use in the future development of new technologies., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: This study sought to show and analyze the main authors' experience (P.R. and J.M.C.) in previously coiled aneurysm surgery as an emerging challenge in today's neurosurgical practice., Methods: Twelve female and 8 male patients, whose ages ranged from 32 to 56 years (average 43.5), underwent surgery between April 2009 and September 2012 in 2 centers. Reasons for surgery were 13 partially occluded aneurysms and 7 recanalized aneurysms., Results: There was no mortality in this series. Aneurysmal sites were 5 anterior communicating artery aneurysms, 5 posterior communicating artery aneurysms, 3 middle cerebral artery aneurysms, 6 paraclinoid carotid artery aneurysms, and 1 aneurysm in the pericallosal artery. A patient sustained a postsurgical frontal infarction with mild neurological deficit. One of the aneurysms presented with an arterial branch at the level of the aneurysmal neck; therefore, partial clipping and packing was required. Microsurgical clipping in the remaining patients was performed successfully. Eight cases required partial coil removal before clipping., Conclusions: Surgical management of previously coiled aneurysms is an emerging challenge in neurosurgery. Incomplete or ineffective embolizations pose an increased risk for the patient, thus requiring surgical treatment. Although not advisable, coil removal might be necessary when in the vicinity of the aneurismal neck in order to place the clip correctly. The authors believe that adequate patient selection and careful preoperative planning are essential to reduce the incidence of patients with unsuccessful coils who will later need surgical treatment., (Copyright © 2014 Elsevier Inc. All rights reserved.)