When Microsurgery Becomes the Only Lifesaving Resource: An Institutional Experience Treating Patients from Low-Income Backgrounds Affected by Posterior Circulation Brain Aneurysms

Abstract

Background and objective Aneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern area of sophisticated technological advancements, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of considering the clinical setting in the treatment decision algorithm.Methods The authors conducted a retrospective review of the health records of patients receiving microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed.Results Surgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (62%), followed by the PCA (23%) and PICA (15%). Among neurological complications, 25% of patients developed paresis of the oculomotor nerve. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale score of 0–2).Conclusion The present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not yet available. Importantly, this clinical setting pressure can provide an imperative need to strive for microsurgical mastery and an opportunity for neurosurgeons in training to gain a competitive advantage.