Work

Keyhole Mini-Pterional Craniotomy for Clipping of Bilateral Middle Cerebral Artery Aneurysms

Year: 2025

Type: article

Abstract: Middle cerebral artery aneurysms remain excellent candidates for microsurgical treatment, despite proliferation of new endovascular tools. Nonetheless, patients desire less invasive options for permanent, durable treatment of aneurysms 1 ; this is particularly the case for patients presenting without subarachnoid hemorrhage and patients with multiple aneurysms that may require several surgical approaches. Keyhole craniotomies, when properly used in well-selected patients, allow for minimally invasive treatment of both ruptured and unruptured cerebral aneurysms, including bilateral aneurysms, which may be treated from a single approach. 2 Middle cerebral artery bifurcation aneurysms are ideal for application of the keyhole concept, as they are located at the depth from the skull under a direct, linear path of access; obtaining early proximal control of the inflow vessel can be accomplished with minimal further dissection at the depth of a narrow corridor; there are few perforators that require dissection; a properly placed craniotomy exposes the entire proximal sylvian fissure as well as the contralateral sylvian contents; sharp dissection of the sylvian fissure further expands the corridor, which can be illuminated with lighted instruments as needed; and conversion to a larger craniotomy can be easily performed is bailout is necessary. A relative contraindication of this approach is if both aneurysms are laterally projecting, although in experienced hands this remains only a relative contraindication. A possible potential complication that the surgeon should be prepared for beforehand is intraoperative rupture of the distal aneurysm, but as demonstrated in Video 1 , it is critical that the surgeon obtain proximal and distal control of the most distal aneurysm as would be obtained from an ipsilateral approach. We demonstrate in Video 1 the use of this approach for bilateral unruptured middle cerebral artery aneurysms, highlighting nuances for successful performance of this operation.

Source: World Neurosurgery

DOI: 10.1016/j.wneu.2025.123702

Authors: Brandon L. King, Andy A. Cannon, Sean M. Krahenbuhl, Errol Gordon, Tyler Auschwitz, M. Yashar S. Kalani

Institution: St. John Medical Center

Language: English

Topic: Intracranial Aneurysms: Treatment and Complications

Subfield: Neurology

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: hybrid

Estimated APC paid: $3,943