The ventral route to intracranial aneurysm: from the origin towards modern transsphenoidal surgery. An historical review and current perspective

Abstract

Objective: A review of the main studies that have explored the use of the ventral pathway for treatment of intracranial aneurysms,including the recent reported extended transsphenoidal approaches. Methods: A comprehensive literature review was performed using the PubMed database. We recovered 48 cases of cerebral aneurysms, approached via the transcervical-transclival, transoral-transclival, transfacial-transclival ventral pathways and the extended transsphenoidal route. The overall rates of complications and surgical success were evaluated and compared for both traditional ventral and transsphenoidal approaches. Results: For traditional routes, the overall complications and surgical success rates were 74% (26/35) and 87% (13115), respectively.For extended transsphenoidal approaches were 44% (4/9) and 78% (7 /9), respectively. Conclusion: Our paper is a reconnaissance of what has been done via "the anterior route" and a notification of the existence of this "surgical window': Present and future of cerebral aneurysm treatment is represented by the endovascular technique. A few selected cases in specialized centers, where transsphenoidal approaches with the aid of the endoscope are routinely performed,may be treated with such techniques alone or in combination with other different procedures. Further studies in large numbers of patients will be required to validate the full benefit of this approach.

Surgical Clipping of Intracranial Aneurysms Using a Transcranial Neuroendoscopic Approach

“…It is more frequently used for real transcranial endoscope-controlled clipping procedures because it increases light intensity in the surgical field and augments the visual field [20]. In the 1990s, endonasal approaches were discarded for aneurysms mainly due to a narrow surgical corridor, limitations for skull base reconstruction, and frequent CSF leakage [21]. Fortunately, these shortcomings were addressed by the development of the mucosal nasal septal flap and novel skull base surgery techniques in the 2000s.…”

Repair of internal carotid artery injury with aneurysm clip during endoscopic endonasal surgery: illustrative case

“…The use of extended endoscopic endonasal approaches for microsurgical clipping of intracranial aneurysms has been reported previously. 24 , 25 Nevertheless, this technique is reserved for well-selected patients under the care of highly experienced teams. 9 Regardless, this article shows the possibility of treating an acute iatrogenic injury of the ICA with an aneurysm clip, and it is beyond the scope of this article to discuss endoscopic endonasal intracranial aneurysm clipping.…”