Endoscopic-Assisted Contralateral Approach for an Unruptured Superior Cerebellar and Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

Endovascular treatment, with its ever-expanding applications, is mainstay of treating posterior circulation aneurysms. Superior cerebellar aneurysms are unique because multiple studies show that comparable outcome can be achieved by a microsurgical approach as well. We describe a 49-year-old woman who was diagnosed with an unruptured multilobulated anterior communicating artery aneurysm and a broad-based left superior cerebellar artery aneurysm while getting evaluated for headache. After discussing treatment options, including observation, endovascular treatment, and microsurgery, the patient opted for definitive microsurgical clipping.(1) An eyebrow incision and subfrontal approach was chosen.(2-4) Type-B superior cerebellar artery aneurysms are traditionally approached ipsilaterally, and posterior clinoidectomy is often warranted to improve the access. Whereas, a contralateral approach with more medial and oblique angle obviate the need for drilling the posterior clinoid(5) provided that the basilar tip is not high riding. Choosing a contralateral subfrontal craniotomy, the aneurysm can be approached from the nondominant side. An inverted aneurysm clip was used for better visualization.(6,7) An endoscope improved visualization of the oculomotor nerve, the relationship of the aneurysm to the parent artery, and excluded residual neck.(8-10) Indocyanine green angiography confirmed exclusion of aneurysm and patency of normal arteries. Subsequently, the bilobed anterior communicating artery aneurysm was approached through the same corridor and was clipped uneventfully. The patient recovered well from surgery and was discharged without any neurological deficit. After careful assessment of individual skull base anatomy, superior cerebellar artery aneurysms can be approached safely from the contralateral nondominant side by sub frontal craniotomy. The patient consented to the procedure and publication of her images. Image at 1:39 reprinted from Patra et al,(5) Copyright 2016, with permission from Elsevier. Images at 2:26 and 6:22 reprinted from Krammer and Lumenta,(7) Copyright 2010, with permission from the Congress of Neurological Surgeons.