One-Stage Clipping of Bilateral Middle Cerebral Artery Aneurysms Via the Bilateral Pterional Keyhole Approach

Abstract

Five patients aged 55 to 73 years (mean 63 years) underwent one-stage clipping for unruptured aneurysms in the bilateral middle cerebral arteries (mean size 4.5 mm, range 2 to 7 mm) via the bilateral pterional keyhole approach in our institute. Important points are as follows: the head is affixed with no rotation; one side manipulation is started 5 minutes after the other side to avoid conflict of surgical instruments; a 5-cm curvilinear skin incision is made inside the hairline and pterional keyhole craniotomy is made bilaterally using 2 burr holes; the whole operating table is rotated 15 degrees to one side to facilitate the microsurgical trans-sylvian approach and aneurysm clipping; the operating table is rotated to the other side for the contralateral procedure; and particular care is taken to avoid bilateral brain injury. This approach provided minimum but sufficient working space required for trans-sylvian dissection. Aneurysm neck clipping was safely performed in a mean operation time of 5 hours 17 minutes. No complications occurred and satisfactory cosmetic results were obtained in all patients. Postoperative neuroimaging studies exhibited bilateral complete clipping with minimal intracranial air content and minimum consequences of brain retraction. One-stage clipping via the pterional keyhole approach is a safe and effective therapeutic option for small bilateral aneurysms.

Our experience with a single stage bilateral approach for treatment of bilateral middle cerebral artery aneurysms

“…For each type of approach it is extremely important to pay attention to several preconditions in order to perform them safely and effectively. [3,4,6,7] Single stage surgery has the advantages of removing a new risk of bleeding, curative treatment with one-time risk of general anaesthesia, shorter hospital stay and reduced cost in terms of bed charge, investigations and operative expenditure. [3,4,6,7] The most important reason for single stage surgery by bilateral approach is to eliminate the risk of bleeding from unruptured aneurysm in the early or late postoperative period.…”

“…[3,4,6,7] Single stage surgery has the advantages of removing a new risk of bleeding, curative treatment with one-time risk of general anaesthesia, shorter hospital stay and reduced cost in terms of bed charge, investigations and operative expenditure. [3,4,6,7] The most important reason for single stage surgery by bilateral approach is to eliminate the risk of bleeding from unruptured aneurysm in the early or late postoperative period. Two important large studies have showed that associated aneurysm in patients with SAH due to another ruptured aneurysm presents a higher risk for future bleeding than makes aneurysms of similar size with no SAH history [3,4,6].…”

“…[3,4,6,7] The most important reason for single stage surgery by bilateral approach is to eliminate the risk of bleeding from unruptured aneurysm in the early or late postoperative period. Two important large studies have showed that associated aneurysm in patients with SAH due to another ruptured aneurysm presents a higher risk for future bleeding than makes aneurysms of similar size with no SAH history [3,4,6]. Furthermore, the necessity of an aggressive hypertensive treatment for fighting with cerebral vasospasm may carry a potential risk of rupturing for associated untreated aneurysm in the postoperative period.…”

“…Furthermore, the necessity of an aggressive hypertensive treatment for fighting with cerebral vasospasm may carry a potential risk of rupturing for associated untreated aneurysm in the postoperative period. [4,6] Optimal selection of the patient with bilateral MCA aneurysm for a single stage surgery by unilateral or bilateral approach is dependent on a number of parameters such as severity of brain edema, the length of contralateral M1 segment, configuration and projection of the contralateral aneurysm. Presence of an important brain swelling, correlated with recent severe SAH is usually associated with very difficult microdisection and an excessive brain retraction that leads to a single stage bilateral approach choice.…”