RU2823205C1 - Method for preventing and controlling bleeding from aneurysms of ophthalmic segment of internal carotid artery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to neurosurgery. Frontotemporal-sphenoidal craniotomy with a basal resection of the temporal bone scales is performed. Extradural subtemporal approach to an apex of a temporal bone pyramid is performed. When separating and resecting the upper wall of the carotid canal, the roots of the trigeminal and greater petrosal nerves and functionally significant bone structures of the temporal bone pyramid are preserved: an eustachian tube, a cochlea and an internal auditory meatus. Internal carotid artery (ICA) is mobilized in the petrosal part without separation of the neurovascular bundle of the neck, without contact with the dome of the aneurysm of the ophthalmic segment, in a periosteum lining the walls of the carotid canal. ICA is clamped by detachable aneurysmal clips.

EFFECT: method makes it possible to select in advance the petrous part of the ICA without contact with the dome of intradural and transit aneurysms of its ophthalmic segment, to preserve all functionally significant neural, vascular and bone structures of the skull base, effective and safe termination of antegrade blood flow along proximal portions of intracranial part of ICA without isolation of neurovascular bundle of neck, prevention or arrest of possible intraoperative bleeding from ruptured and intact aneurysms of this localization.

1 cl, 19 dwg, 2 ex

Description

The present invention relates to medicine, namely to neurosurgery, and can be used in clipping operations for aneurysms of the ophthalmic segment of the internal carotid artery.

Improving the technique of eradication of cerebral aneurysms remains an urgent problem in operative neurosurgery due to the continuing high level of mortality and disability of patients, especially in the hemorrhagic type of the disease [1].

Performing open operations on cerebral aneurysms is always associated with an increased risk of intraoperative bleeding upon contact with its dome.

Patients with aneurysms of the proximal sections of the intracranial part of the internal carotid artery (ICA), which include the ophthalmic, clinoid and cavernous segments, constitute a special group of patients, which is associated with the complex anatomy and inaccessibility of these sections of the ICA for open interventions;

In this regard, the prevention or stopping of bleeding from intradural and transit (partially located in the clinoid and cavernous sections) aneurysms of the ophthalmic segment of the ICA acquires special importance, since the routine application of temporary clips proximal to the aneurysm, used in the treatment of aneurysms of other localizations, is impossible due to anatomical conditions . Until now, the main method of preventing or stopping bleeding from ophthalmic aneurysms remains exposing the site of division of the common carotid artery into the internal and external carotid arteries in the neck. This method of proximal control involves the use of a second surgical approach, and de facto a second operation, the implementation of which may be complicated by: paresis of the vocal cords and tongue; soft tissue hematoma causing breathing problems; dissection of isolated arteries. Access to the neurovascular bundle of the neck may be difficult or impossible due to the presence of a scar-adhesive process after previous operations or radiation treatment [2].

In addition, clamping of the ICA in the neck may not lead to a complete cessation of antegrade blood flow along the ophthalmic segment of the ICA due to the presence of anastomoses of the internal carotid artery with branches of other brachycephalic arteries distal to the site of clamping [3].

That is why the search for alternative ways to prevent or control possible bleeding from aneurysms of the ophthalmic segment of the ICA continues.

An analogue of the proposed invention is a method for proximal control of possible bleeding from aneurysms of the ophthalmic (paraclinoid) segment of the ICA, proposed by T.M. Wascher et al.[4].

As a surgical approach, the authors used a standard frontotemporal sphenoidal craniotomy followed by an intradural pretemporal approach to the bottom of the middle cranial fossa. The surgeon visually monitored the course of the middle meningeal artery and, after identifying the foramen spinosum, the dura mater was dissected perpendicular to the axis of the pyramid of the temporal bone in the projection of the carotid canal. The trunk of the greater petrosal nerve is transected, after which the upper wall of the carotid canal is resected, followed by mobilization of the petrous part of the ICA. To stop blood flow through the ICA, a Fogarty balloon catheter was installed into the lumen of the carotid canal, which was inflated if necessary.

The disadvantages of this method of treatment include:

1) intradural approach to the base of the middle cranial fossa requires complete mobilization of the pole of the temporal lobe. To do this, the connecting veins along the surgical approach are coagulated and crossed, which significantly increases the risk of developing venous cerebral infarction in the surgical area.

2) Dissection of the temporal bone pyramid using an intradural approach is unsafe, since accurate identification of anatomical structures, damage to which leads to hearing loss and denervation of the facial muscles, is difficult with this approach.

3) Dissection of the dura mater in the projection of the carotid canal is associated with the risk of damage to the internal carotid artery, since the upper wall of the carotid canal in this area is often thinned or absent.

3) Transection of the greater petrosal nerve increases the risk of complications associated with denervation of the lacrimal gland on the access side.

4) The degree of compression of the internal carotid artery during balloon catheter inflation is unpredictable and carries the risk of incomplete occlusion or excessive compression leading to damage to the carotid artery.

The closest analogue of the proposed invention is the method of mobilization of the stony segment of the ICA, proposed by L.N. Sekhar et al [5] to create a shunt between the petrous and supraclinoid parts of the ICA, bypassing its cavernous and clinoid sections.

The authors used orbitozygomatic craniotomy as the surgical approach. Using an extradural subtemporal approach, dissection of the outer wall of the cavernous sinus is performed to isolate the apex of the pyramid of the temporal bone, the greater petrosal and the mandibular branches of the trigeminal nerve. The trunk of the middle meningeal artery is crossed at the point where it passes through the foramen spinosum. The trunk of the greater petrosal nerve is also divided. The superior wall of the carotid canal is drilled lateral to the groove of the greater petrosal nerve in the so-called posterolateral triangle (Glasscock triangle), which is located between the posterior edge of the mandibular nerve root and the cochlea. After opening the carotid canal, the petrous part of the ICA is identified, which is mobilized and a temporary clip is applied to stop the blood flow.

The disadvantages of this method of preventing bleeding include:

1) as the main access, the authors used a craniobasal modification of the standard frontotemporal sphenoidal craniotomy, during which the zygomatic arch is crossed and the orbit is opened. In all cases, the internal carotid artery in the neck is isolated from an additional incision. The use of an extended cranio-orbital approach makes the operation more traumatic, worsens cosmetic results and increases the risk of developing purulent-septic complications.

2) Obligate transection of the greater petrosal nerve increases the risk of complications associated with denervation of the lacrimal gland on the access side.

3) When drilling the upper wall of the carotid canal in the posterolateral triangle, the authors in all cases were forced to open the bony part of the auditory tube, which creates a risk of developing an inflammatory process in the middle ear cavity and hearing loss.

Tasks:

- improve a method for preventing or temporarily stopping bleeding from aneurysms of the ophthalmic segment of the ICA

- reduce the trauma of ICA release in the carotid canal;

- optimize the technique and improve the functional results of open operations in patients with aneurysms of the ophthalmic segment of the ICA;

- exclude damage to the bone part of the auditory tube, which creates a risk of developing inflammatory processes in the middle ear cavity and hearing loss;

- preserve the greater petrosal nerve and, accordingly, the innervation of the lacrimal gland on the access side;

- improve cosmetic results, reduce trauma and the volume of surgical access by preserving the zygomatic arch and the integrity of the orbit;

- carry out an extradural approach to the base of the middle cranial fossa while preserving the connecting veins without the risk of developing venous cerebral infarction in the surgical area;

- carry out an extradural approach to the pyramid of the temporal bone with safe and accurate identification of anatomical structures while maintaining hearing and innervation of the facial muscles;

- exclude dissection of the dura mater above the internal carotid artery and the risk of damage to the latter.

The essence of the invention is; in that during isolation and resection of the upper wall of the carotid canal, the roots of the trigeminal and greater petrosal nerves are preserved; as well as functionally significant bone structures of the temporal bone pyramid: the Eustachian tube, the cochlea and the internal auditory canal. The internal carotid artery is mobilized in the stony part without isolating the vascular bundle of the neck, without contact with the dome of the aneurysms of the ophthalmic segment, in a “case” of periosteum lining the walls of the carotid canal, the internal carotid artery is clamped with removable aneurysmal clips.

Technical result: the method makes it possible to isolate in advance the stony part of the internal carotid artery without contact with the dome of intradural and transit aneurysms of its ophthalmic segment. The proposed technique for isolating the ICA makes it possible to preserve all functionally significant neural, vascular and bone structures of the skull base. The proposed method allows you to effectively and safely stop antegrade blood flow through the proximal sections of the intracranial part of the ICA without isolating the neurovascular bundle of the neck and, thereby, prevent or control possible intraoperative bleeding from ruptured and intact aneurysms of this location.

Implementation of the treatment method: under general anesthesia, after rigid fixation of the head in a Mayfield clamp, treatment and draping of the surgical field, a standard frontotemporal sphenoidal craniotomy is performed with additional basal resection of the temporal bone squama. Using an operating microscope and microsurgical techniques, the dura mater (DRM) covering the bottom of the middle cranial fossa is peeled off. An extradural subtemporal approach is performed to the anterior surface of the pyramid of the temporal bone. After identifying the foramen ovale, the outer wall of the cavernous sinus is dissected to expose the outer surface of the mandibular nerve root. Bleeding from the sinus is stopped with coagulation and hemostatic material "Surgicel". Next, the greater petrosal nerve is identified, from which transection is refrained. In order to prevent traction damage to the facial nerve, the isolation of the greater petrosal nerve from the dura mater covering it is carried out along the groove of the same name in the direction from front to back in the direction of the cleft of the greater petrosal nerve. At the next stage, the dura mater is peeled off medial to the groove of the greater petrosal nerve up to the upper edge of the pyramid of the temporal bone. Thus, the apex of the temporal bone pyramid is skeletonized in the posteromedial triangle (Kawase triangle).

To identify the site of exit of the ICA from the canal of the same name, the mandibular nerve root is mobilized anteriorly. Next, trepanation of the upper wall of the carotid canal is performed. To do this, the apex of the temporal bone pyramid is precisely resected with a high-speed drill and pistol cutters medial to the groove of the greater petrosal nerve (in the posteromedial triangle) in an area of 7 by 5 mm. Particular attention is paid to maintaining the integrity of the greater petrosal and trigeminal nerves; ICA trunk.

The internal carotid artery in the lumen of the carotid canal is surrounded by a network of small veins forming a venous plexus; therefore, the periosteum lining the internal lumen of the carotid canal along the entire circumference is carefully peeled off and the carotid artery is mobilized in the “periosteal sheath” without provoking venous bleeding.

Temporary cessation of blood flow through the ICA is carried out by applying removable temporary clips that have a branch compression force that is safe for the vascular wall. To do this, the ICA trunk is grasped and gently squeezed with microvascular forceps, after which two temporary vascular clips are sequentially applied so that the antegrade blood flow through the ICA is completely stopped. To restore blood flow, the clips are sequentially removed using a clip-on applicator.

Having ensured the safety of manipulations in the more distally located areas of the ICA using the method described above, the anterior inclined process located in close proximity to the aneurysm is resected, the removal of which is necessary for clipping the majority of ophthalmic (paraclinoid) aneurysms of the ICA.

After performing all the manipulations planned by the extradural approach, the dura mater is opened in an arcuate manner, turned anteriorly and basally in such a way as not to interfere with the application of temporary clips to the ICA isolated in the carotid canal. Next, an intradural approach to the ophthalmic segment of the ICA is performed, and the aneurysm is isolated and clipped.

Twelve patients were operated on using this method in a clinical setting; in all cases, hearing was preserved, no venous cerebral infarctions were observed, and there was no damage to the facial nerve. We present two clinical examples: in the first case with an intradural, and in the second with a transit aneurysm of the ophthalmic segment of the ICA.

For a better understanding of the method of preventing or controlling bleeding from aneurysms of the ophthalmic segment of the internal carotid artery, copies of the drawings are provided in the appendix to the examples: FIG. 1 - Cerebral angiograms of patient G. before surgery. A large aneurysm of the ophthalmic (paraclinoid) segment of the left internal carotid artery is identified, Fig. 2 - Intraoperative photographs of patient G. Marking of the surgical approach, fig. 3 - Intraoperative photographs of patient G. Left frontotemporal sphenoidal craniotomy with additional basal resection of the squama of the left temporal bone and the wing of the sphenoid bone. The initial stage of the extradural subtemporal approach, Fig. 4 - Intraoperative photograph of patient G. The petrosal segment of the left ICA in the carotid canal and the greater petrosal nerve are visualized, Fig. 5 - Intraoperative photograph of patient G. A large ruptured aneurysm is identified in the ophthalmic segment of the left ICA with the superomedial direction of the dome. The left optic nerve is “spread out” on the dome of the aneurysm and displaced medially, Fig. 6 - Intraoperative photograph of patient G. Stage of temporary clipping of the left ICA in the carotid canal, Fig. 7 - Intraoperative photograph of patient G. Significant reduction of blood flow in the aneurysm against the background of temporary clipping of the left ICA in the carotid canal. The neck of the aneurysm and the mouth of the left ophthalmic artery are visualized, Fig. 8 - Intraoperative photograph of patient G. The neck of the aneurysm of the left ICA is isolated and clipped with two permanent aneurysmal clips "Aesculap". The dome of the aneurysm is opened and coagulated, Fig. 9 - Computed tomography angiograms of patient G. after surgery. The left ICA aneurysm is not contrasted; blood flow along the left ICA, its main and functionally significant branches is preserved, Fig. 10 - Cerebral angiograms of patient M. before surgery. A ruptured aneurysm of the right internal carotid artery at the origin of the posterior communicating artery. Intact aneurysms: ophthalmic and clinoid segments of the left internal carotid artery, Fig. 11 - Intraoperative photograph of patient M. Left frontotemporal sphenoidal craniotomy with additional basal resection of the squama of the left temporal bone and the wing of the sphenoid bone. The initial stage of the extradural subtemporal approach, Fig. 12 - Intraoperative photograph of patient M. Trepanation of the upper wall of the carotid canal with preservation of the greater petrosal nerve. The petrosal segment of the left ICA is visualized, Fig. 13 - Intraoperative photograph of patient M. Extradural subtemporal approach. Resection of the left anterior oblique process, fig. 14 - Intraoperative photograph of patient M. A transit aneurysm of the ophthalmic segment of the left ICA is identified, Fig. 15 - Intraoperative photograph of patient M. A transit aneurysm of the ophthalmic segment of the left ICA is visualized. The left optic nerve is pushed upward and medially. The mouth of the left ophthalmic artery is visualized, Fig. 16 - Intraoperative photograph of patient M. The neck of the aneurysm of the ophthalmic segment of the left ICA is clipped with 2 permanent “Aesculap” clips, fig. 17 - Intraoperative photograph of patient M. The neck of the aneurysm of the clinoid segment is isolated and clipped with a permanent aneurysmal miniclip “Aesculap”, fig. 18 - Intraoperative photograph of patient M. Fluorescein angiography of the artery of the left carotid system, the left ophthalmic artery is filled antegrade. Aneurysms are not contrasted, Fig. 19 - Cerebral angiography of patient M. after surgical treatment. Aneurysms on the right and left are not contrasted.

Example 1. Patient G., 59 years old, was admitted to the neurosurgical department of the hospital with the diagnosis: “Rupture of an aneurysm of the ophthalmic (paraclinoid) segment of the left internal carotid artery (dated January 28, 2023). Subarachnoid-ventricular hemorrhage." After further examination and final verification of the diagnosis (Fig. 1) - according to cerebral angiography, a large aneurysm of the ophthalmic segment of the left internal carotid artery was determined, the patient was taken to the emergency operating room, where he underwent the operation: “Pterional craniotomy on the left. Mobilization of the left ICA in the carotid canal. Extradural resection of the left anterior oblique process. Clipping of a paraclinoid aneurysm of the left ICA.”

Under general anesthesia, the patient's head is turned to the right and rigidly fixed in the head holder. After standard processing and draping of the surgical field in the left frontotemporal region, an arcuate incision of soft tissues was made in the shape of a “question mark” (Fig. 2) - the surgical approach was marked. A left-sided frontotemporal sphenoidal craniotomy was performed with additional basal resection of the scales of the left temporal bone and the wing of the sphenoidal bone (Fig. 3) - frontotemporal sphenoidal craniotomy with additional basal resection of the scales of the left temporal bone and the wing of the sphenoid bone, the initial stage of the extradural subtemporal approach . Using an operating microscope and microsurgical technique, an extradural subtemporal approach was used to perform trephination of the upper wall of the carotid canal, followed by mobilization of the petrosal part of the right ICA (Fig. 4) - the petrosal segment of the left ICA in the carotid canal and the greater petrosal nerve were visualized. Next, resection of the left anterior oblique process was performed using an extradural method. The dura mater is opened in an arcuate manner. Brain with traces of acute hemorrhage. The parasellar and interpeduncular cisterns were sequentially dissected. The left ICA is isolated. A large ruptured aneurysm was discovered emanating from the superior wall of the ophthalmic segment of the ICA distal to the orifice of the ophthalmic artery with the dome in a superomedial direction. The left optic nerve is “spread out” on the dome of the aneurysm and displaced medially (Fig. 5) - a large ruptured aneurysm is identified in the ophthalmic segment of the left ICA with the superomedial direction of the dome, the left optic nerve is “spread out” on the dome of the aneurysm and is displaced medially. The dome of the aneurysm is fused with the dura mater covering the left anterior oblique process. The membranous part of the optic nerve canal and the distal dural ring were dissected. Against the background of temporary clipping of the left ICA in the carotid canal (Fig. 6) - the stage of temporary clipping of the left ICA in the carotid canal, blood flow in the aneurysm decreased significantly, which made it possible to visualize the neck of the aneurysm and identify the mouth of the left ophthalmic artery (Fig. 7) - significant reduction in blood flow in the aneurysm against the background of temporary clipping of the left ICA in the carotid canal, the neck of the aneurysm and the mouth of the left ophthalmic artery are visualized. With further isolation of the aneurysm, it ruptured. Low-intensity bleeding was controlled by applying additional temporary clips to the left ICA (distal to the aneurysm) and the aneurysm dome. Against the background of complete cessation of blood flow along the left ICA, the neck of the aneurysm is isolated and clipped with two FT784T “Aesculap” clips. There is no bleeding after the temporary clips are removed. The dome of the aneurysm is coagulated (Fig. 8) - the neck of the aneurysm of the left ICA is isolated and clipped with two permanent aneurysmal clips "Aesculap", the dome of the aneurysm is opened and coagulated. Visually, the left ICA, its main and functionally significant branches are passable. Hemostasis. Control of the surgical wound for foreign bodies. Plastic surgery of dura mater defects at the base of the skull with free muscle flaps and hemostatic sponge. The main incision of the dura mater is sutured tightly. The dura mater is sutured around the perimeter of the bone window. The bone flap is placed in place, fixed to the dura mater and the edges of the defect. Layer-by-layer suturing of the surgical wound leaving vacuum drainage according to Redon.

The postoperative course is smooth. Regression of cerebral and meningeal symptoms was noted. The appearance of new neurological symptoms associated with the course of the underlying disease and the surgical approach performed was not noted. During control CT-AG: the aneurysm is not contrasted; blood flow along the left ICA, its main and functionally significant branches is preserved (Fig. 9) - the aneurysm of the left ICA is not contrasted, blood flow through the left ICA, its main and functionally significant branches is preserved. After complete healing of the surgical wound, the patient was discharged home in satisfactory condition on the 17th day from the onset of the disease.

Example 2. Patient M., 49 years old, was admitted to the neurosurgical department on December 2, 2022 with a diagnosis of “Multiple cerebral aneurysms. Ruptured aneurysm of the right internal carotid artery at the origin of the posterior communicating artery. Subarachnoid hemorrhage (from November 27, 2022). Intact aneurysms: ophthalmic and clinoid segments of the left internal carotid artery,” (Fig. 10) - according to cerebral angiography, a ruptured aneurysm of the right internal carotid artery at the origin of the posterior communicating artery, intact aneurysms of the ophthalmic and clinoid segments of the left internal carotid artery are determined. Considering the bilateral location of the aneurysms, a decision was made to conduct staged treatment. The first stage, on December 3, 2022, the patient underwent the following operation: “Osteoplastic craniotomy on the right. Ventriculocystenostomy. Clipping of a ruptured aneurysm at the mouth of the right posterior communicating artery. The postoperative course is smooth. Regression of cerebral and meningeal symptoms was noted. The appearance of new neurological symptoms associated with the course of the underlying disease and the surgical approach performed was not noted. Healing by first intention. The second stage of treatment without discharge from the hospital on December 22, 2022. The patient underwent surgery: “Pterional craniotomy on the left. Mobilization of the left ICA in the carotid canal. Extradural resection of the left anterior oblique process. Clipping of intact aneurysms of the ophthalmic and clinoid segments of the left ICA.”

Under general anesthesia, the patient's head is turned to the right and fixed in a head holder. After standard preparation and draping of the surgical field, an arcuate soft tissue incision was made in the left frontotemporal region. A left-sided frontotemporal-sphenoidal craniotomy was performed with additional resection of the basal scales of the left temporal bone and the wing of the sphenoidal bone (Fig. 11) - left-sided frontotemporal-sphenoidal craniotomy with additional basal resection of the scales of the left temporal bone and the wing of the sphenoid bone, the initial stage of extradural subtemporal approach. Using an operating microscope and microsurgical equipment, an extradural subtemporal approach was used to perform trepanation of the upper wall of the carotid canal, preserving the greater petrosal nerve and subsequent mobilization of the petrosal segment of the left ICA (Fig. 12) - trepanation of the upper wall of the carotid canal, preserving the greater petrosal nerve, visualizing the petrosal segment of the left ICA . Next, an extradural subfrontal approach was used to perform resection of the left anterior oblique process (Fig. 13) - extradural subtemporal approach, resection of the left anterior oblique process. The dura mater is opened in an arcuate manner. The brain has no traces of acute hemorrhage. The parasellar cisterns were dissected using the transsylvian approach. The left ICA is isolated. An aneurysm of the ophthalmic segment of the left ICA with a superomedial direction of the dome was discovered without signs of a previous rupture. The aneurysm is “transit” - the proximal part of the neck and dome is located in the clinoid segment of the left ICA (Fig. 14) - a transit aneurysm of the ophthalmic segment of the left ICA is determined. The left optic nerve is “spread out” on the dome of the aneurysm and pushed medially and upward. After resection of the “optical support”, dissection of the membranous part of the optic nerve canal and partial dissection of the distal dural ring, it was possible to mobilize the dome, visualize the neck of the aneurysm and identify the orifice of the left ophthalmic artery (Fig. 15) - a transit aneurysm of the ophthalmic segment of the left ICA, the left optic nerve is visualized pushed upward and medially, the mouth of the left ophthalmic artery is visualized. Against the background of temporary clipping of the left ICA in the carotid canal for 6 and 5 minutes with reperfusion for 10 minutes, the neck of the aneurysm is isolated and clipped with 2 “Aesculap” clips: FT742T, FT720T (Fig. 16) - the neck of the aneurysm of the ophthalmic segment of the left ICA is clipped with 2 permanent clips "Aesculap." The dome of the aneurysm was opened and coagulated.

The next stage continued dissection of the distal dural ring. An aneurysm of the clinoid segment of the left ICA with a posterior direction of the dome was detected. The proximal part of the neck and the dome of the aneurysm are located intracavernosally. Partial dissection of the proximal dural ring was performed. Bleeding from the cavernous sinus was stopped with Surgicell tamponade. The neck of the aneurysm is isolated and clipped with an FT710T miniclip (Fig. 17) - the neck of the aneurysm of the clinoid segment is isolated and clipped with a permanent aneurysmal miniclip “Aesculap”. During control intraoperative fluorescein angiography, the arteries of the left carotid system, including the left ophthalmic artery, are filled antegrade. Aneurysms are not contrasted (Fig. 18) - fluorescein angiography of the artery of the left carotid system, the left ophthalmic artery is filled antegrade, aneurysms are not contrasted. Hemostasis. Control of the surgical wound for foreign bodies. Plastic dura mater with a free periosteal flap. Plastic surgery of defects in the bones of the base of the skull and dura mater with a free muscle flap using BioGlue sealant. The bone flap is placed in place, fixed to the dura mater and the edges of the defect. Layer-by-layer suturing of the surgical wound. Iodine. Aseptic dressing.

The postoperative course is smooth. Regression of the existing cerebral and meningeal symptoms was noted. The appearance of new neurological symptoms associated with the course of the underlying disease and the surgical approach performed was not noted. During control cerebral angiography, blood flow through the left and right ICA, their main and functionally significant branches was preserved; aneurysms are not contrasted (Fig. 19) - cerebral angiography after surgical treatment, aneurysms on the right and left are not contrasted. After complete healing of the surgical wound, she was discharged home in satisfactory condition on the 9th day after the second operation.

Literature

1) Tawk, R.G. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage / R.G. Tawk, T.F. Hasan, C.E. D'Souza, J.B. Peel, W. D. Freeman // Mayo Clin. Proc. - 2021. - Vol. 96(7). - P. 1970-2000. doi: 10.1016/j.mayocp.2021.01.005.

2) Jani, P. Safe Cervical ICA Control for Clipping Clinoid-Ophthalmic Segment ICA Aneurysms / P. Jani, S.N. Mathuriya, S. Dhandapani // Turk Neurosurg. - 2021. - Vol. 31(5). - P. 821-822. doi: 10.5137/1019-5149.JTN.32688-20.1.

3) Babichev, K.N. Segmental agenesis of the cervical segment of the internal carotid artery with collateral blood supply from the ascending pharyngeal artery and intercavernous anastomosis (clinical observation and literature review) / K.N. Babichev, A.V. Savello, D.V. Svistov, D.V. Kandyba, E.M. Barashkov // Journal “Problems of Neurosurgery” named after N.N. Burdenko. - 2018. - Vol. 82(2). - pp. 81-87.

4) Wascher, T.M. Improved transdural exposure and temporary occlusion of the petrous internal carotid artery fbr cavernous sinus surgery. Technical note / T.M. Wascher, R.F. Spetzler, J.M. Zabramski // J Neurosurg. - 1993. - Vol. 78(5). - P. 834-837. doi: 10.3171/jns.l993.78.5.0834.

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Claims (1)

A method for preventing or stopping bleeding from aneurysms of the ophthalmic segment of the internal carotid artery, including frontotemporal sphenoidal craniotomy with basal resection of the scales of the temporal bone, an extradural subtemporal approach to the apex of the pyramid of the temporal bone, characterized in that during isolation and resection of the upper wall of the carotid canal the roots are preserved trigeminal and greater petrosal nerves, functionally significant bone structures of the temporal bone pyramid: the Eustachian tube, cochlea and internal auditory canal, the internal carotid artery is mobilized in the petrous part without isolating the neurovascular bundle of the neck, without contact with the dome of the aneurysms of the ophthalmic segment, in a “case” from the periosteum lining the walls of the carotid canal, clamping of the internal carotid artery is carried out with removable aneurysmal clips.