Microsurgical Management of Blister-Type Basilar Artery Apex Region Aneurysms: Companion Cases Demonstrate Technical Nuances of the Subtemporal Approach: 2-Dimensional Operative Video

The proportion of intracranial aneurysms treated by microsurgical clip ligation has drastically decreased in the endovascular era. However, some aneurysms cannot be treated by current endovascular techniques. Therefore, trainees and young vascular neurosurgeons must develop and maintain microsurgical skills to safely treat aneurysms that require surgery. Ruptured, basilar artery apex, blister-type aneurysms are particularly treacherous and require a high degree of skill to safely manage them surgically. In this video, 2 companion cases are exhibited to demonstrate the nuances of the subtemporal, skull base, approach to the basilar apex region. In each case, the patient consented to surgery and anonymized recording. The subtemporal approach is favored over the trans-sylvian for posteriorly directed basilar apex region aneurysms as the former affords a complete view of the relevant anatomy. Points for consideration include variations on the standard subtemporal approach, use of retractors vs lumbar drainage to mobilize the temporal lobe, and splitting the tentorium vs a suture-retraction technique for visualization of the basilar artery apex region. Techniques for successful navigation of intraoperative rupture are demonstrated. As the number of intracranial aneurysms treated by microsurgery continues to ebb, high-quality educational videos that supplement surgeon experience will become increasingly critical to ensure that a cohort of capable microvascular neurosurgeons is prepared to tackle challenging, but manageable aneurysms, such as the blister-type basilar apex variety. Video (c) Emory University School of Medicine, 2021. Used with permission.