Surgical Approaches to

Intracranial Aneurysms

Gregory G. Heuer. Michael T. Lawton H. Richard Winn. Peter D. LeRoux

Fendi

Introduction
Intracranial aneurysms can be occluded using direct
surgical techniques, endovascular approaches,
combined surgical and endovascular strategies, or
indirect techniques such as revascularization
procedures or parent vessel occlusion.
The goal of intracranial aneurysm surgery is to
obliterate the aneurysm while flow in the vessels
associated with the aneurysm is maintained

 there are several techniques that are common to all

aneurysms, including patient selection and diagnostic
studies, anesthetic techniques, positioning,
neuromonitoring, and brain relaxation that should
be considered before surgery.
In this chapter we briefly discuss microsurgical
techniques common to all aneurysms, including
preoperative considerations, aneurysm exposure,
dissection, temporary occlusion, and aneurysm
occlusion approaches to the anterior and
posterior circulation.

Preoperative Considerations

Neurodiagnostic Studies (Computed Tomography, CT

Angiography, Magnetic Resonance Imaging,
Angiography)
Anesthesia
Brain Relaxation
Positioning
Neuromonitoring
Craniotomy Selection

ANTERIOR ClRCULATION
Most anterior circulation aneurysms can be approached
through a pterional craniotomy, including aneurysms of
the ICA, posterior communicating artery (PcomA),
anterior communicating artery (AcomA), and middle
cerebral artery (MCA).

Carotid Ophthalmic Artery and Paraclinoid

ICA Aneurysms
Extradural ACP removal is feasible for most ophthalmic
segment aneurysms, but intradural ACP removal is
preferred for large, complex, or ruptured aneurysms. In
addition, an intradural approach is recommended for
clinoidal segment aneurysms, especially those of the
anterolateral segment because these lesions may
adhere to or erode into the ACP.

Intradural ACP Removal

Extradural ACP Removal

Internal Carotid and Posterior Communicating

Artery Aneurysms
Posterior Communicating Artery
There are four important surgical principles:
1. Avoid temporal lobe retraction because this may
avulse an aneurysm stuck to the temporal lobe.
2. Identify the AChA.
3. An overlying aneurysm may obscure the PComA origin
and course.
4. Ensure that the clip blades are not too long to prevent
III nerve injury.

Posterior ICA Wall Aneurysms

Anterior Cerebral and Anterior Communicating

Artery Aneurysms
The usual pterional craniotomy is extended more medial
and the sphenoid wing and anterior fossa floor are
flattened. An orbital zygomatic (OZ) approach may be
helpful for superior oriented AcomA aneurysms.
The key to successful AcomA aneurysm occlusion is
complete appreciation of the AcomA complex anatomy
aneurysm morphology influences how this may be achieved
To understand dissection, AcomA aneurysms may be
classified into one of four projections based on their
orientation in true anatomic space.

 Superior: aneurysms project into the interhemispheric

fissure and the fundus often obscures the contralateral All A1
junction
Anterior: these lesions fill the space between the two optic
nerves and so may obscure the contralateral optic nerve.
Posterior: aneurysms project both above and below the
plane formed by the A1 segments and often obscure the
take-off of the contralateral A1
Inferior: these aneurysms are "under" the AcomA in the
region of the hypothalamic perforating arteries that arise
from the AcomA.

Middle Cerebral Artery

Aneurysms
1. Medial transsylvian : The sylvian fissure is opened from medial
to lateral, the ICA followed to its bifurcation, and the MCA trunk
defined
2. Lateral transsylvian : The sylvian fissure IS dissected from
lateral to medial and so this approach is quicker than a medial
transsylvian approach; there is less CSF loss because the basal
cisterns are not opened, less retraction, and the transsylvian
veins may be better preserved.
3. Superior temporal gyrus : A 2- to 3-cm incision that extends
posteriorly from just behind the anterior sylvian fissure is made
in the superior temporal gyrus parallel to the sylvian fissure.

POSTERIOR CIRCULATION
About 10% to 15% of intracranial aneurysms are located in the posterior
circulation where they occur most often at the basilar bifurcation, followed by
the origins of the superior cerebellar artery (SCA) and posterior inferior
cerebellar artery (PICA).

Basilar Bifurcation (Apex)

Between 5% and 8% of intracranial aneurysms are
located at the basilar bifurcation or apex (BB).

Subtemporal
There are several disadvantages to the subtemporal
approach:
(1) the operating field is small;
(2) excess temporal lobe retraction may be necessary;
(3) the ipsilateral P1 lies between the surgeon and the
aneurysm, which may limit dissection or clip
application;
(4) the aneurysm, particularly when large, needs to be
retracted to see the opposite P1; and
(5) a high-lying bifurcation may be difficult to approach.

Orbitozygomatic-Pterional
Approach
This approach is useful for a high bifurcation and provides a more anterior
trajectory, a higher view above the posterior clinoid process, and greater
space in the operative corridor than a standard pterional craniotomy.

Transpetrosal Approaches
Transpetrosal approaches expose the basilar trunk from a lateral
trajectory through presigmoid corridors in the petrous bone
categorized into three variations based on an increasing extent of
resected bone: retrolabyrinthine, translabyrinthine, and
transcochlear

Extended Middle Fossa

Approach
1) removal of the Kawase triangle;
2) removal of the Glasscock triangle;
3) removal of the cochlea together with skeletonization
of the anterior internal auditory canal;
4) inferior displacement of the zygoma

ANEURYSM OCCLUSION
There are several basic principles to be understood during
aneurysm exposure:
(1) aneurysms usually arise at the branch site on the parent
artery;
(2) aneurysms arise at turns or curves in an artery;
(3) aneurysms point in the direction that blood would flow if
the curve at the aneurysm site was not present (i.e., in the
direction of maximal hemodynamic thrust); and
(4) there often are perforating arteries near most
aneurysms that need to be preserved

There are several basic tenets when temporary occlusion is used:

(1)temporary vessel occlusion should be used selectively and the
risk of rupture versus ischemia be balanced;
(2)Perforating vessels' patency must be maintained;
(3)hypotension during temporary occlusion should to be
(4)safe occlusion time varies with aneurysm location, patient age,
and clinical condition
(5)intermittent reperfusion may increase tolerable occlusion time;
and
(6)neuroprotection is recommended

CONClUSIONS

The surgical treatment of intracranial aneurysms can be

complex and challenging. There are some general
principles that are common to all aneurysms, which if
followed for all surgeries can facilitate the effective
treatment and minimize complications. The most
important factors relate to surgical planning and an
understanding of the cerebral vascular anatomy of
the patient and the aneurysm of the patient.