17 Anterior Circulation Aneurysms

Vascular Neurosurgery
17
Anterior Circulation Aneurysms
ALEXANDER M. MASON, DANIEL LOUIS BARROW
CLINICAL PEARLS
• Although endovascular intervention is an important part of the • Cotton (in addition to patties) is an important adjunct to
treatment of aneurysms, expertise and proficiency in open aneurysm repair and allows for retractorless surgery in many
surgical management of cerebral aneurysms are essential instances.
requirements. • Becoming efficient and precise with Sylvian fissure dissection
• Each aneurysm location requires its own unique set of nuances and opening will facilitate all aneurysm surgeries, and these are
and methods, which are essential for proper and safe clip basic techniques that need to be mastered.
ligation.
Introduction magnetic resonance imaging (MRI), which are performed for

other clinical reasons; however, as many as 50% of aneurysms
Intracranial saccular or berry aneurysms are common, occur- are found after an initial subarachnoid hemorrhage.9 Although
ring in approximately 1% to 3% of the population.1 Based on screening studies of CT and MRI are useful, computed tomog-
a review of 1450 unruptured intracranial aneurysms (UIAs) in raphy angiography (CTA) and magnetic resonance angiogra-
83 study populations, the overall prevalence is estimated to be phy (MRA) can typically define the location and morphology
3.2%, with a mean age of 50 years and a higher prevalence in of aneurysms with a greater degree of certainty. Aneurysms that
women, in patients with autosomal dominant polycystic are >3 to 4 mm are commonly identified on these noninvasive
kidney disease, and in those with a family history of a ruptured imaging studies, depending on the equipment, software, and
cerebral aneurysm.2 Other associated disorders with a higher clinical experience.10,11 For routine screening or following
incidence of intracranial aneurysms include multiple endo- intracranial aneurysms, noninvasive imaging studies are pre-
crine neoplasia type I,3 hereditary hemorrhagic telangiectasia,4 ferred when possible, and although these can also be used for
Ehlers-Danlos syndrome type IV,5 neurofibromatosis type I,6 treatment planning in some situations, catheter angiography
and Marfan syndrome.7 remains the gold standard for defining aneurysms and their
Anterior circulation aneurysms comprise roughly 85% of morphology. The advent of three-dimensional (3D) rotational
intracranial aneurysms and are classified based on their ana- angiography has significantly improved the ability to resolve
tomic location,8 most commonly at the anterior communicat- and model the angioarchitecture, associated perforators, and
ing artery, middle cerebral artery bifurcation, ophthalmic parent vessels.
artery, and the branching points of the internal carotid artery
(ICA), including the ophthalmic, superior hypophyseal, pos- Anatomy
terior communicating, and anterior choroidal arteries and the
ICA bifurcation (Table 17.1). The cavernous segment of the A comprehensive understanding of the vascular anatomy along
ICA is also a common location for aneurysm formation. These with a robust knowledge of aneurysm location and nuances are
aneurysms are generally extradural and have a different natural of supreme importance. There are general tenets that apply
history and set of therapeutic options. to all intracranial aneurysms, as well as location-specific
nuances should be considered. Anatomy, both general vascular
Imaging anatomy and that of aneurysms and other cerebral vascular
disease, should be a fundamental foundation that can help
Intracranial aneurysms are increasingly found on cross-sectional with the study and mastery of cerebral aneurysms and their
imaging studies, including computed tomography (CT) and treatment.
264
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CHAPTER 17 Anterior Circulation Aneurysms 265
TABLE A1 M1 CN II
Anterior circulation aneurysms
17.1 Distal ring
Aneurysm Location Frequencya
C7 Tentorium
Cavernous part of carotid artery 8.3%
C6
Internal carotid artery 29.9% C5
Anterior communicating or anterior cerebral 12.3% ACP C4
artery
Proximal ring
Middle cerebral artery 29.0%
C3
Posterior communicating artery 8.5%
Petrolingual
Vertebrobasilar system (other than basilar tip) 4.9%
ligament C2
Tip of basilar artery 7.0%
a
Reported frequencies result from the International Study of Unruptured
Intracranial Aneurysms (ISUIA) trial of 4060 patients.
Carotid
canal
C1
Internal Carotid Artery
ECA
The origin of the ICA in the neck is usually lateral to the
external carotid artery at the bifurcation and courses cephalad ICA
toward the skull base. Carotid-basilar anastomoses are impor-
tant to recognize, both diagnostically and in treatment plan-
ning. Most common is the primitive trigeminal artery (PTA),
which connects the cavernous ICA with the embryonic dorsal Common
longitudinal neural arteries.12 Beginning at the bifurcation, the carotid artery
carotid is divided into seven numbered and named segments,
each identifying its anatomic location: C1, cervical segment; • Figure 17.1 The segments of the carotid artery. The segments of the
C2, petrous segment (vertical and horizontal segments); C3, internal carotid artery are as follows: cervical segment, or C1; petrous
lacerum segment; C4, cavernous segment; C5, clinoidal segment, or C2; lacerum segment, or C3 (together C2 and C3 compose
the “petrous portion”); cavernous segment, or C4, (functionally identical
segment; C6, ophthalmic segment; and C7, the communicat- to the commonly used “cavernous portion”); clinoidal segment, or C5;
ing segment13 (Fig. 17.1). ophthalmic or supraclinoid segment, or C6; and communicating or termi-
Anatomically, the cervical segment (C1) begins at the carotid nal segment, or C7 (C6 and C7 together constitute the commonly used
bifurcation (at approximately the fourth cervical vertebra) and “supraclinoid segment”).
courses to the skull base. The petrous segment (C2) begins at
the entrance of the carotid into the carotid canal at the base of
the skull, where it courses vertically then horizontally (antero- least partially intradural and within the subarachnoid space.
medially). The ICA then exits the carotid canal, to begin the The carotid siphon, also known as the anterior loop (in the
lacernal segment (C3), where the carotid continues over the Dolenc classification), contains the distal cavernous segment,
foramen lacerum; this short segments ends at the petrolingual the entire clinoidal segment, and the proximal ophthalmic
ligament.14 The cavernous segment (C4) passes through the segment.15 The communicating segment (C7) begins at the
cavernous sinus, from the lateral dural ring proximally, and posterior communicating artery and concludes at the ICA
exits at the distal dural ring. The clinoidal segment (C5) rep- bifurcation, where the ICA divides into the anterior and middle
resents a very short segment that extends from the distal to cerebral arteries.
the proximal dural rings, beneath the anterior clinoid process. Branches that are diagnostically or clinically relevant are
The ophthalmic segment (C6) starts at the proximal dural important to understand and identify. The cervical segment
ring, whereby the carotid enters the subarachnoid space, and (C1) has no regular branches. The petrous segment (C2) has the
ends at the posterior communicating artery. The absence of caroticotympanic artery and, inconsistently, the vidian artery.
a reliable angiographic landmark at the clinoidal-ophthalmic The cavernous segment (C4) has several branches including
(C5–C6) junction makes this difficult to identify on angiog- the meningohypophyseal artery, which divides into the inferior
raphy; adjunctive studies such as MRI or CTA can be helpful. hypophyseal artery, the dorsal meningeal artery and the tento-
The C6 segment gives rise to the ophthalmic artery, and this rial artery of Bernasconi and Cassinari, the inferolateral trunk,
has traditionally been used to help identify the beginning and the capsular arteries of McConnell. Although these rep-
of this segment. In practice, cerebral aneurysms that are at, resent important functional vascular components and can be
or distal to, the ophthalmic artery are considered to be at involved in dural arteriovenous fistulas as well as blood supply
266 PART 3 Vascular Neurosurgery
to meningiomas, they do not regularly play a role in cerebral variants have been commonly described, with duplication,
aneurysms. Additionally, cavernous segment aneurysms are not triplication, fenestrations, loops, and other anomalies often
infrequently identified, but, with exceptions that are typically found. The A2 segment extends from the ACOMM of the
limited to giant aneurysms, they are extradural. Unfortunately, corpus callosum. The orbitofrontal and frontopolar arteries
large or strategically placed aneurysms can occasionally become branch consistently from this segment. At the rostrum of the
symptomatic from focal pressure on structures within the corpus callosum, the A2 branches into the pericallosal artery,
cavernous sinus and may require treatment—typically using now A3, and its more superficial branch, the callosomarginal
endovascular techniques. Although the ophthalmic segment artery. This represents a common site of aneurysm formation
(C6) gives rise to the ophthalmic artery in 90% of anatomic in this segment, and anatomic variability typically is seen with
dissections,16 in a small percentage of cases it may originate the location of the branch site. The callosomarginal artery,
in the clinoidal segment (C5) or, rarely, more proximally. A which travels in the cingulate sulcus, branches into the medial
branch of the ophthalmic artery, the lacrimal artery, gives rise frontal artery and the paracentral artery. A common anatomic
to the recurrent meningeal artery, passes retrograde through variant is the absence of the callosomarginal artery, with ter-
the superior orbital fissure, and anastomoses with branches minal branches arising directly from the pericallosal artery.
of the middle meningeal artery, which can have important Distal A3 branches include prefrontal (often from the calloso-
clinical implications.12 Additionally, a number of extraorbital marginal artery), paracentral, and parietal branches.
ophthalmic artery branches have extensive anastomoses with The second main trunk from the ICA bifurcation is the
ethmoidal and facial branches of the external carotid artery and middle cerebral artery (MCA). The MCA begins at this major
can be an important source of blood flow to the distal ICA in branch point and travels within the Sylvian fissure (lateral
the event of a more proximal occlusion. The second important fissure) to yield multiple branches (Fig. 17.3). The branching
named artery of the C6 segment is the superior hypophyseal and origin of the MCA are relatively consistent anatomically,
artery (SHA); this and the ophthalmic artery can be sites although variants exist including duplication or hypoplasia.
of aneurysm formation. The communicating segment (C7) The M1 segment travels deep within the Sylvian fissure, and its
has two branches. First, the posterior communicating artery orientation and length are variable. The medial lenticulostriate
branches inferolaterally and immediately wraps beneath, trav- arteries branch from the M1 segment are of great importance
eling posteriorly to merge with the posterior cerebral artery clinically, and their presence and preservation should be empha-
(PCA) at the P1–P2 junction. A fetal PCA is a normal variant sized. Knowledge of these when dissecting along the M1, as
of the circle of Willis, where the ipsilateral P1 is atretic or well as preservation with manipulation of this larger segment,
hypoplastic, and the dominant supply to the distal posterior prevents damage. Larger named branches along this segment
cerebral artery is from the posterior communicating artery. As include the anterior temporal and polar temporal arteries, either
such, when a fetal PCA is identified, it must be preserved. The of which can serve as bypass donor arteries if needed.
second branch is the anterior choroidal artery, which may be The MCA bifurcation, like the anterior communicating
duplicative and is also a common site of aneurysm formation. artery complex, is variable. Classically, the bifurcation branches
The ICA terminus is the bifurcation of the A1 and M1, and into a superior and an inferior division, whereas in approxi-
it has distal branches that perforate the anterior perforating mately 15% of patients a trifurcation is identified. Other pat-
substance and supply the internal capsule. terns are also seen, including separating into multiple small
The anterior cerebral artery (ACA) arises from the ICA branches. Generally, when a superior trunk is identified, it will
above the optic nerve as A1 and travels ventromedially to the supply branches in the lateral frontobasal artery, prefrontal
anterior communicating artery complex (ACOMM); during sulcal artery, and precentral and central (rolandic) terminal
this course it has several (as many as 12) medial lenticulostriate branches. The inferior trunk forms inferior temporal branches
arteries that branch both posteriorly, supplying the anterobasal (anterior, middle, and posterior), an angular branch, and often
brain, and inferiorly, supplying the optic chiasm and nerves two parietal branches (anterior and posterior). Variability is the
(Fig. 17.2). Additional perforators can come posteriorly from rule with terminal branches, and variances are expected. Iden-
the ACOMM to supply the hypothalamus and the columns tifying the vascular anatomy for a given patient is of particular
of the fornix as well as other structures, and as such, oblitera- importance in patients with MCA pathology, as small branches
tion of the communicating artery in aneurysm management are often obscured from the surgeon’s view.
should be avoided whenever possible. The recurrent artery (of
Heubner) is the largest and typically the longest ACA perfora-
tor, which branches from the proximal A2 or distal A1. The The Surgical Approach to Anterior
ACOMM can be hypoplastic or atretic in some patients, but Circulation Aneurysms and General Tenets
the patency of the lenticulostriate arteries can be assumed to
be present. The common aneurysms of the anterior circulation are typi-
After branching to the contralateral A1 segment through cally related to the branch points of the named intracranial
the communicating artery, within the interhemispheric fissure, vessels and include the cavernous carotid, ophthalmic and
the A2 segment transverses the interhemispheric fissure, superior hypophyseal, posterior communicating anterior cho-
paired with its contralateral counterpart. Variability of the roidal, and ICA blister and terminus aneurysms, anterior com-
communicating segment is the rule, and a number of anatomic municating artery and pericallosal aneurysms, and middle
Paracentral A IIPA
SIPA Precuneal A
PMFA
IMFA
y
ter
Ar
al
AMFA
os
all
ric
Pe
A3-A5
A2
A1
CmaA
FpA LSAs
RAH
OfA
MCA
ACoA
PCoA
ICA
• Figure 17.2 The anterior cerebral artery is divided into five segments, A1 through A5. A1 includes the
anteromedial central (medial lenticulostriate), the recurrent artery of Heubner (variable), and the anterior
communicating artery. A2 branches include the orbitofrontal artery (medial frontal basal) and the fronto-
polar artery. A3, also termed the pericallosal artery, gives rise to the callosal marginal artery and then
terminates as the internal parietal arteries (superior, inferior) and the precuneal artery. The callosal marginal
artery in turn branches into the medial frontal arteries (anterior, intermediate, posterior) and the paracentral
artery. A4 and A5 segments are the distal smaller branches, often named the callosal (supracallosal)
arteries.
cerebral artery and distal middle cerebral artery aneurysms. agents (eg, propofol or phenobarbital) in the room should be
The locations of aneurysms in the International Study of ensured. Although rarely needed, we have our anesthesiolo-
Unruptured Intracranial Aneurysms (ISUIA) retrospective gists prepared to administer adenosine to achieve temporary
cohort in patients without a history of subarachnoid hemor- cardiac arrest in the event of a catastrophic intraoperative
rhage (SAH) demonstrated that ICA and MCA aneurysms are rupture. Although the bleeding of an unruptured aneurysm
the most frequent.17 is exceedingly rare upon dural opening, giant or atypically
Prior to opening the dura, several points of emphasis should adherent aneurysms are more susceptible to rupture. Ruptured
be made, and although this applies to anterior circulation aneurysms are more likely to rerupture while opening the
aneurysms, it can be carried forward to all types of cerebro- dura because of the changes in pressure associated with this
vascular surgery. Prior to opening the dura, communication opening. As such, the well-prepared aneurysm surgeon should
with anesthesia regarding the completion of administration of have several adjuncts available prior to opening the dura. The
osmolar agents such as mannitol should be discussed, along microscope with the mouthpiece should be balanced, draped,
with end tidal CO2 levels using effective neuroanesthesia tech- and the light source powered on. If the surgeon prefers to
niques. We typically administer 0.5 to 1 g/kg of mannitol on use a chair, this should also be draped and positioned. The
both ruptured and unruptured cerebral aneurysm cases to aid aneurysm clips and microsurgical instruments should be open
in brain relaxation, to minimize or eliminate retraction, and for and prepared; a temporary clip should be loaded and avail-
its neural protective benefits.18 Availability of neuroprotective able. Although retractors should be avoided in routine surgery
prerolandic A
postrolandic A
APBr
Prefrontal sulcal A PPBr

F
PTBr
LSAs
MTBr
Frontobasal A ATBr
ATA
M3 PTA
M2
M1 T
• Figure 17.3 The middle cerebral artery is divided into four segments, M1 through M4. M1 includes
the medial and lateral lenticulostriates, the anterior temporal artery, the polar temporal artery, and, variably,
the uncal artery. The M2 branches include the frontal and temporal branches, and named branches from
these are considered M3 branches. The frontal branch includes the frontobasal artery, the prefrontal sulcal
artery, and the pre-/postrolandic arteries. The temporal branches include anterior, middle, and posterior
branches as well as the anterior and posterior parietal branches. M4 is composed of arterial branches
emerging from the named branches within the Sylvian fissure onto the convex surface of the hemisphere,
also known as the cortical segments.
whenever possible, the retractor system should be attached, identify the normal and diseased vasculature. The subarach-
loaded, and positioned so that it can be utilized at a moment’s noid space is divided into cisterns, which are connected by
notice if needed. For very large or proximal aneurysms, con- arachnoid membranes, and it is filled with cerebrospinal fluid
sideration of carotid artery exposure in the neck should be (CSF), leading from the cortical surface to the basilar cisterns.
evaluated and discussed. The time required for even the most By opening these planes, it allows egress of CSF, which pro-
efficient carotid artery exposure can be catastrophic with a vides intrinsic brain relaxation, and provides visualization of
hemorrhage, in particular if only a single surgeon is scrubbed. the vascular anatomy. Having a working knowledge of the
Lastly, the patient should have been “typed and crossed” for cisterns and the vascular contents allows the neurosurgeon to
blood, and depending on the hospital where the surgery is use the subarachnoid planes to their advantage. Careful dissec-
being performed, either the blood bank should be notified tion through the interconnected cisterns allows a surgical plan
or the blood should be available in the room. Having these to be executed while following the vascular tree to the aneu-
general tenets in mind before opening the dura can change an rysm and related vessels.
unexpected rupture from being a disaster to being a controlled Subarachnoid dissection should be performed sharply,
situation that can be addressed efficiently. beginning at the cortical surface. The Sylvian cistern contains
The subarachnoid space and its dissection are of paramount the M1 and its branches, as well as the origins of the lenticu-
importance for safe aneurysm dissection and treatment. In the lostriates, the temporopolar and anterior temporal arteries, the
unruptured setting, this plane can provide a beautiful corridor MCA bifurcation, and the origins of its major branches. For
to the skull base and its contents, including the circle of Willis; both the orbitozygomatic and pterional approaches, the Sylvian
in contrast, in the ruptured aneurysm setting, this same space fissure is best approached from the cortical surface and is
is filled with blood and can present a challenge to safely opened sharply from distal to proximal, using great care to
In addition, although the presence of a hematoma or subarach-

noid blood can be a determinant in some cases, in other cases
cA
post-Ro this can be followed and evacuated, allowing a more expedi-
tious exposure of the fissure. After an acute subarachnoid hem-
orrhage, the initial opening of the Sylvian fissure may be
challenging. Often, the thick subarachnoid blood can obscure
identification of the fissure itself. A useful technique is to use
a tuberculin syringe to inject air into the Sylvian fissure before
opening the cistern. The air will fill the subarachnoid spaces
and make the initial opening more straightforward.
Depending on the location of the aneurysm, a few other
Prefrontal sulcal A PP
general tenets can guide the surgeon with dissection, and
F although they are applied to the Sylvian dissection and offer
PTBr access to the circle of Willis, they can and should be applied
LSAs to most approaches. Having a clear understanding of the loca-
MTBr tion, morphology, and size of the aneurysm is of paramount
asal A * importance. Identification of the distal arterial branches in the
*
ATBr
base of the fissure allows them to be followed proximally to
the larger trunk vessels. The extent of proximal dissection
should be guided by three principles. The identification of the
ATA
proximal artery in a perforator-free zone that can be safely and
temporarily occluded if desired or needed should be a high
+ priority. Having access to “proximal control” is not only a
fundamental tenet of cerebrovascular surgery, but it allows
PTA unexpected ruptures to have the potential of salvage and
success. Second, the dissection should be adequate to relax the
brain and to provide a tension-free working zone that can
T
eliminate the need for retractors and optimize working angles.
Lastly, consideration should be given to a potential donor
vessel in the event a bypass is required. In some cases, a proxi-
mal artery can or will serve as a donor vessel for a bypass (eg,
anterior temporal artery), and if so, this should be exposed
adequately. Alternatively, the superficial temporal artery should
• Figure 17.4 The Sylvian fissure dissection with several important be preserved when possible during opening, particularly for
tenets: the clear reflection of the veins inferiorly, with a focus on vein
ICA and MCA aneurysms. The temptation to minimize the
preservation, and identification of the base of the fissure and the M2 seg-
ments (*). Atraumatic and retractor-less dissection should be the goal dissection to the aneurysm and the immediate vessels in the
whenever possible. Dissection follows the distal M2 segments proximally vein by hurriedly clipping the aneurysm because of the fear of
to the middle cerebral artery bifurcation adjacent to the limen insula (+). rupture should be avoided. For a majority of aneurysms that
are exposed using the transsylvian approach, exposure of the
opticocarotid cistern for both proximal vessel identification in
avoid injury to distal arterial branches and Sylvian veins19 (Fig. a perforator-free zone and the ability to open the basilar cis-
17.4). We typically open this fissure distal to proximal, super- terns to allow egress of CSF should typically be considered. In
ficial to deep, with the immediate goal of identifying the M2 subarachnoid hemorrhage cases, we typically open the lamina
branches, which can be followed to the M1 branch. It is terminalis to allow further egress of CSF and lower the risk of
important to avoid the temptation to work through a narrow subsequent hydrocephalus in some patients.
corridor, but rather open the cortical surface along the entire The venous drainage pattern of the Sylvian fissure varies
distance of the fissure, first in a superficial and then on a second tremendously, and although the unique anatomy of the venous
pass, a middle plane, and then conclude on a deep plane, where drainage itself is not the primary consideration with regard to
the M2 vessels and its branches lie. The orientation of the dissection, adaptation to the patient’s anatomy while reflecting
fissure will vary depending on the position of the head, but it the veins temporally should be emphasized. In addition, the
is invariably in an oblique-inferior direction. MCA aneurysms preservation of the cerebral veins, although traditionally
within the Sylvian fissure, such as an MCA bifurcation aneu- regarded as of secondary importance, cannot be emphasized
rysm, require an adaptation of this technique (see the Middle enough. Kageyama and associates21 noted that the preservation
Cerebral Artery Aneurysms section, presented later). Respect- of cerebral veins was the single most important prognostic
ing the Sylvian fissure also allows for safe passage along the factor contributing to morbidity in patients undergoing crani-
frontal and temporal lobes and avoids damage to the language otomy for a cerebral aneurysm. This was later supported by
areas of the dominant hemisphere and the rolandic fissure.20 Spetzler and colleagues,22 who showed that patients with an
altered superficial middle cerebral vein on postop angiogram must be revisualized, mentally adjusting the trajectory to the
were more likely to have cerebral edema, and although these new angle. It is necessary to avoid the over-magnification of
and other studies have limitations, most experienced aneurysm angles where this site is obscured. Although distal control is
surgeons appreciate the importance of meticulous dissection not frequently needed, ICA aneurysms (C6 and C7 segments)
techniques and venous preservation. can occasionally require distal control because of the robust
A few additional nuances regarding dissection and exposure collateral blood flow available; if this is a concern, identifying
should be emphasized. Dissecting on the perforator free area these distal control points prior to further dissection is of vital
of a vessel where a temporary clip may be applied is of supreme importance. Although temporary vessel occlusion is an impor-
importance. The undersurface of the M1 branch and the A1/ tant adjunct to aneurysm surgery, care should be exercised in
ICA terminus are to be respected and avoided unless absolutely its use. Woetgen and colleagues found that during temporary
necessary. As the surgeon continues to work proximally, pro- clip occlusion, there was a trend toward greater postoperative
gressively identifying locations for temporary clips that avoid ischemic injury and vasospasm in patients who underwent
these perforator zones allows for safe temporary occlusion if temporary clipping for ruptured aneurysms, and greater ische-
necessary. Yasargil introduced the importance of sharp dissec- mia trends in the MCA group with longer occlusion times.23
tion; this technique, along with a meticulous, clear field, During this preliminary dissection, after the proximal
should be emphasized. A microsuction, microscissors with a occlusion zones are identified and the location of the aneurysm
sharp bayonetted forceps or bipolar cautery forceps, and a is generally identified, the orientation and associated vessels are
Rhoton dissector are the most common instruments for Sylvian then identified and sharp dissection continues. With the ori-
fissure dissection and should be viewed as surgical “anchor” entation and identification of the complex now completed, this
instruments. The brain should be protected with Surgicel is often an opportunity to review necessary imaging by com-
(Ethicon, Inc, Somerville, New Jersey), moist cotton patties, paring and contrasting by memory or in real time the identi-
or Teflon, except the area that is immediately being dissected. fied anatomy and angiographic anatomy. “It is said that if you
The use of surgical cotton balls or wisps placed within the know your enemies and know yourself, you will not be imper-
fissure allows for atraumatic dissection and dynamic retraction, iled in a hundred battles.”24 This is of particular importance
and these items serve as intrinsic hemostatic agents that maxi- with identification of and exploring for associated vessels. As
mize surgical efficiency. one begins to dissect and appreciate the morphology of the
Surgical dissection should be performed in a repeatable neck and the dome of the aneurysm during this preliminary
pattern whenever possible. Using a stepwise approach allows dissection, the “provisional aneurysm neck” is identified and a
for different levels of efficiency and lessens the chance of missed provisional permanent clip is selected and loaded to allow for
steps that may be critical to the outcome of the surgery. The potential clip application in the setting of an unexpected hem-
fissure dissection, followed by the preliminary and then the orrhage, although this should be avoided unless absolutely
final dissection in discrete steps, should be entertained. We necessary. Lastly, communication with the operating room
have found that it is less traumatic to avoid fixed retractors and team, including the surgeon’s assistants, is important at this
to instead use instruments for dynamic retraction. This is fol- juncture, and the scrub nurse should review anticipated instru-
lowed by the clipping and final evaluation steps. The level of ments. The team will often appreciate a moment of pause.
organization and a stepwise approach will vary by surgeon, but
a patterned and precise approach should be utilized by all Final Dissection
skilled cerebrovascular surgeons.
Occasionally, the preliminary and final dissection can occur
Preliminary Dissection simultaneously, but for the novice surgeon, they should be dis-
crete, deliberate, and precise steps. The final dissection involves
As the Sylvian fissure (or interhemispheric fissure in the case defining the exact neck and the precise trajectory needed for
of pericallosal aneurysms) is efficiently and atraumatically ideal clip application. The small or adherent vessels should be
opened as noted previously, the preliminary dissection of the dissected off of the dome where necessary, but this step can be
aneurysm now begins. This consists of several steps and is avoided if it is not necessary to apply the clip without com-
highly dependent on the location and angioarchitecture of the promising the vessel. Only vessels that are likely in the path
aneurysm. During this preliminary dissection, the exact loca- of the clip blades, are at risk of occlusion because of torsion
tion of the aneurysm is generally identified—the aneurysm of the neck or sac, or are otherwise at risk should be dissected
itself it not dissected at this point. The orientation of the dome or freed. Very often a partial or intentional incomplete dissec-
and adjacent vessels are identified. The provisional temporary tion will free the vessel enough to allow the clip to be safely
clip is now selected, and a trial of placing the clip on the applied behind the vessel. The small surrounding vessels or
proximal segment is tested to ensure the proper clip has been veins should be protected, as all too often they will obscure,
identified and that it has been loaded correctly. Often a paddy or begin to bleed and thereby obscure, the final views needed;
is placed in line with this segment so that if the aneurysm wisps of cotton are ideal for this final preparation. Sharp dissec-
unexpectedly ruptures, this paddy can be followed to the proxi- tion is the rule, and this is often where inexperienced surgeons
mal control site and a clip can be applied. With every move- will dissect inadequately, but it is indeed where meticulous
ment of the microscope onward, the proximal occlusion site dissection is of paramount importance.
The final dissection may or may not include the dome of versus DSA, both modalities produced equally low rates of
the aneurysm; this will depend on the size, location, and pres- unexpected aneurysm filling, parent vessel compromise, and
ence of attached vessels and the overall location of the lesion. perioperative strokes, suggesting that ICGA may be an accept-
Generally, the larger the aneurysm, the less likely the clipping able replacement for intraoperative DSA in selected patients.25
will benefit from dissection of the full dome, but there are Any imperfections should immediately be corrected using a
clear advantages of full manipulation and control of the entire careful and deliberate move of readjusting the clip. Any remain-
aneurysm. In much the same way, whether a temporary clip ing dog-ears can usually be eliminated by clip readjustment or
is applied for this final dissection phase or clip application the addition of another clip.
is an individual decision. Doing so can lessen the anxiety of Although clip selection and clip patterns are challenging
final dissection to some extent, as well as reduce the tension and require experience and planning, a few principles should
of the vessels or sac, which can simplify the final dissection be kept in mind. If the clip is felt to be imperfectly placed,
and clipping. Temporary occlusion, as has been noted, can avoid the temptation to open it partially and move it; rather
come with potential complications and occasionally a false make it a well-calculated maneuver. If the clip can be left in
sense of security. Lastly, insonation with a micro-Doppler of place and a second clip can be safely applied to perfect the
the exiting or distal vessels with attention to the tone and construct, this option should be considered. Occasionally, a
character can be invaluable, and even with the advent of indo- small thin-walled neck or aneurysm remnant that was used to
cyanine green (ICG) videoangiography the micro-Doppler reconstruct the vessel may bleed after the clip is applied; in this
plays a vital role, which can be checked and rechecked and is case, placing a small piece of cotton under the tine of the clip
complementary to ICG. We typically also have the anesthesia and capturing it with closing can provide a permanent and
team prepare the ICG and place it “in line” but with firm immediate hemostasis, without having to occlude the neck
instructions not to inject until someone from the team has further.
heard specifically from the surgeon to inject the ICG at the Calcification or atherosclerosis of the neck should be con-
appropriate time. sidered and evaluated during the final dissection phase prior
to clipping whenever possible. If the clip does not purchase at
Clipping the intended closing site, repositioning the clip farther away
from the neck may allow additional purchase. The danger is
With proper preparation and exposure, clip application should that the incorporated calcium may occlude the parent or the
not be the most challenging part of the surgery, but clip selec- distal vessels with manipulation. It also may make the effective
tion and application are critical. Although there are specific closure of the clip or obliteration of the aneurysm impossible.
clip configurations for specific aneurysm locations, the ulti- Occasionally, novel clip strategies need to be incorporated or
mate clip selection is highly individualized based on the angio- booster clips that increase the closing force of the aneurysm
architecture of the specific aneurysm. Considerations include need to be used. A primary fenestrated clip with a second short
a construct that completely eliminates the aneurysm from the clip overlying the fenestration can also be used to increase the
circulation while maintaining patency of the parent vessels and closing force over a shorter individual clip segment. Experi-
associated branches. In general, the shortest clip possible to enced surgeons occasionally will externally compress the neck
accomplish complete occlusion of the neck is best, to avoid to break up the calcium in extreme situations. Bypassing a
unintentional occlusion of normal vasculature beyond the diseased segment is rarely necessary but should be in the sur-
distal neck. We find that a temporary clip applied at this point geon’s armamentarium.
allows for a softening of the sac, and a final check with a dis-
sector can be completed to visualize the neck and associated
vessels. Once applied, the temporary clip is removed with Final Evaluation
caution, first opening the blades without removing the clip to
ensure no unexpected bleeding is encountered; if there is bleed- Once the surgeon is satisfied with the initial evaluation of
ing, reapplying the clip after identification of the source is the clip construct anatomically, by Doppler and then ICG,
often required. Once the clip is applied, the length of the clip a final evaluation should be done. The surgeon will ensure
tines should be explored immediately to be sure the neck is that there are no unintended implications of the construct
completely secured and the clip does not compromise the sur- on adjacent structures when brain is in situ and that there is
rounding vasculature. Although exploration under the operat- no unexpected rotation of the construct or expected hemor-
ing microscope is essential, external visualization is often rhage from adjacent vessels with removal of the adjuncts. An
inadequate to determine patency of the parent vessel and intraoperative angiogram is the gold standard approach to
branches. This is particularly true of large aneurysms and those ensure complete obliteration of the aneurysm and filling of
with thick walls. A micro-Doppler, ICG videoangiography, the normal vasculature. Distal emboli or other unexpected
and intraoperative digital subtraction angiography (DSA) are complications from the angiogram should be weighed with
all useful adjuncts for reinsonation and to document complete the importance of gaining diagnostic information regarding
obliteration of the aneurysm and normal filling of the sur- the vascular anatomy of both the visualized and the nonvi-
rounding vasculature. In a recent single center analysis compar- sualized anatomy—something that is only possible with an
ing intraoperative indocyanine green angiography (ICGA) angiography.
Anterior Circulation Aneurysm Subtypes treatment of proximal ICA aneurysms. Although extradural
removal of the clinoid is described in oncologic approaches,
Each aneurysm has unique challenges. Knowledge of the because of the possibility of adherence and the inadvertent
unique nuances of specific aneurysms and their pitfalls will rupture of proximal ICA aneurysms, this action should be
keep a well-prepared surgeon from avoiding common compli- avoided. During extradural dissection, we aggressively remove
cations and will ideally improve the patient’s care and outcome. the lesser wing of the sphenoid and the posterior third of the
orbit, leaving the remainder of the anterior clinoid process
Proximal Internal Carotid Artery Aneurysms for the intradural portion of the procedure. After opening
the dura in an arc from the medial point of the entry of
Cavernous segment aneurysms are unique in terms of natural the optic nerve to a point lateral to the ICA (distal dural
history and therapeutic options. Because these aneurysms are ring), this is reflected inferiorly over the ICA and optic nerve
extradural, they are associated with a benign natural history (Fig. 17.5). Although we have used a diamond-bit drill and
and often require no treatment. When symptomatic, they are a 1-mm Kerrison rongeur in the past, we now prefer to use
most often treated by endovascular means in this era. Clinoidal an ultrasonic aspirator to remove the roof of the optic nerve
segment aneurysms lie between the two dural rings and are not and the anterior clinoid process. The optic strut now remains
within the subarachnoid space unless they grow to such a size between the optic nerve and the carotid artery. There is often
that they pierce the dural ring. The ophthalmic segment of the cavernous venous bleeding at this phase that can be controlled
ICA may give rise to aneurysms at the origin of the ophthalmic with powered procoagulants. The optic strut is then either
or superior hypophyseal arteries. egg shelled or snapped off, depending on the location of the
As noted previously, ophthalmic artery aneurysms arise aneurysm and the thickness of the strut. Waxing of the bone
from the superior surface of the ICA just beyond the origin edges prevents the infrequent but nefarious CSF leak at this
of the ophthalmic artery (OA), following the expected linear site. With these three steps completed, the distal dural ring
flow of the blood at the terminus of the carotid siphon. This and falciform ligament can then be opened sharply to expose
anatomically complex area deserves special mention and study, the clinoidal segment of the ICA, which exposes aneurysms of
as an understanding of this segment will facilitate its treat- that segment and provides proximal control and exposure of
ment when needed. In approximately 10% of patients, the the proximal neck of OA and SHA aneurysms. If the dural ring
OA branches more proximally, either from the cavernous is being opened to expose a SHA aneurysm, the ring opening
carotid or, more commonly, the clinoidal (C5) ICA. The SHA should be extended circumferentially as much as possible to
branches arise medially and are slightly more distal than the allow mobilization and visualization of the aneurysm on the
ophthalmic artery. The lateral component of the siphon flow ventral-medial surface of the ICA. Additionally, opening of
vector is the hemodynamic component of SHA aneurysms the falciform ligament over the optic nerve allows mobilization
as compared with the superior oriented vector seen with OA of the nerve and decompresses the tether that can sometimes
aneurysms. be seen with ophthalmic segment aneurysms. If the proximal
There are multiple anatomic nuances that make proximal neck of the aneurysm is well visualized, removal of the anterior
ICA aneurysms challenging to treat, and these should be con- clinoid process is not necessary and potential morbidity may
sidered with treatment planning. Proximal control of an oph- be avoided.
thalmic segment aneurysm may be obtained at the clinoidal A proximal temporary clip location is now identified. If one
segment after removal of the anterior clinoid process, at the is using the clinoidal segment for proximal control, a mini-
petrous segment, or by exposing the cervical carotid. The cervi- temporary clip to maximize visualization is preferred if possi-
cal carotid artery should be prepped and within the field in all ble. Clip selection will depend on the origin of the aneurysm
proximal carotid aneurysm cases, and it is prudent, but not and its specific configuration. In general, the ideal clip for an
necessary, to consider opening the neck at the beginning of the ophthalmic artery aneurysm is a side-angled clip that ends up
case, particularly for a novice surgeon. If the neck is opened, with the blades parallel to the axis of the ICA. Superior
a double vessel loop should be placed around the cervical ICA hypophyseal aneurysms typically require a fenestrated clip,
and loosely attached. The plan of opening the neck only after where the fenestration is used to reconstruct the lumen of the
proximal control is needed should be avoided; a small cervical ICA with the blades on the ventromedial surface of the ICA
incision heals in most patients, and the exposure takes little to obliterate the aneurysm. Preliminary dissection should also
time. For clinoidal segment aneurysms, the clinoidal segment address the optic nerve and tether points, although the manip-
of the ICA may not be available for proximal control and the ulation of the nerve should be minimized (Fig. 17.6).
petrous or cervical carotid should be considered. Final dissection should proceed with caution. SHA aneu-
When operating on proximal ICA aneurysms, the surgeon rysms are challenging because the normal carotid artery is
should always be prepared to remove the anterior clinoid between the surgeon and the neck of the aneurysm on the
process for adequate exposure of aneurysms involving the cli- ventral surface of the ICA and because the optic nerve overlays
noidal or OA segment. The anterior clinoid process is a bony the superior portion of the ICA at this level. Mobilization of
ridge, forming the roof of the optic canal, and is attached the optic nerve can minimize trauma to this nerve if manipula-
below by the optic strut. Understanding the relation of the tion is necessary and where the value of removing the clinoid
clinoid with the ICA and optic nerve is essential for the safe and optic canal roof can carry significant advantages.
Oph A
Incision
CN II
Optic
strut
ICA
A1
M1
A B
Optic strut
Distal
dural ring
C
• Figure 17.5 The anatomy of a right-sided intradural clinoidectomy. (A) Sharply incise the dura in a
T-shaped manner over the anterior clinoid process (ACP), with a medial extension past the optic nerve
(II). (B) Diamond-bit drilling of the anterior clinoid process occurs under continuous irrigation until the roof
of the optic canal, the orbital apex, and the optic strut are exposed. (C) The final work after “egg shelling”
the bone can be done with a microcurette or a 1-mm Kerrison rongeur. With the final bone removal,
cavernous venous bleeding can be tamponaded with hemostatic agents. With the C6 ophthalmic segment
now fully exposed, identification of the proximal carotid and neck of the aneurysm is now possible. Resec-
tion of further components of the distal dural ring is now possible, if needed.
and it lies immediately adjacent to the opticocarotid triangle,

so that the surgeon dissects the fissure using a trajectory that
is frontally oriented while minimizing traction on the temporal
lobe. Second, dissecting through the fissure and following the
Oph A M1 branch to the bifurcation, and maintaining the dissection
on the cephalad rather than the lateral aspect of the vessel, are
vital steps to complete while identifying the opticocarotid tri-
angle contents as initial objectives. On rare occasions, the
Proximal anterior clinoid process may obscure a PCOM aneurysm, and
dural ring proximal control at the cervical carotid with or without removal
C5
of the anterior clinoid process may be necessary. The prelimi-
C6 Distal nary dissection should seek to identify the ACH; ideally pre-
dural ring
operative imaging will guide the surgeon with regard to its
association with the neck of the aneurysm. Occasionally, the
An table or microscope will need to be changed to a more lateral-
medial trajectory at this point. Identification of both proximal
and distal control sites should be completed at this juncture,
and the former can be occasionally challenging as the optic
ICA
nerve and the clinoid process are often blocking clear access.
Placing a temporary clip, if needed, within the immediate
vicinity of the aneurysm typically will mitigate any advantage
A1 of using this. Opening the falciform ligament just lateral and
M1 parallel to the optic nerve enlarges the landing zone for a tem-
porary clip, as can removing the anterior clinoid process if
• Figure 17.6 Unruptured anatomy of ophthalmic aneurysm, internal needed.
carotid artery, and optic nerve. The three-dimensional anatomy of the The final dissection should seek to isolate and protect the
proximal and distal dural ring is shown, with the origin of the ophthalmic ACH if not already done. This will involve dissection of the
artery. The distal dural ring and the relationship of the ophthalmic artery
and aneurysm are variable and often best defined in surgery.
neck and specifically determining whether the ACH is coming
entirely from the PCOM or whether it also involves the ICA
proper. Identification of the oculomotor nerve during the final
dissection will minimize trauma and avoid unintended injury
Posterior Communicating and Anterior (Fig. 17.7). A fixed retractor is rarely required, but if needed,
Choroidal Artery Aneurysms placing it only on the frontal lobe, parallel to the fissure and
the optic nerve, is preferred. Final dissection of first the distal
The posterior communicating artery (PCOM) and anterior neck and the exact location of the ACH, and then proximally,
choroidal artery (ACH) branch laterally from the communi- to identify the PCOM, and its relation with the ICA and the
cating segment of the ICA, prior to its bifurcation into M1 aneurysm, is then completed. Finally, the plane between the
and A1. They are intimately associated with each other. The PCOM and the aneurysm itself is defined using a Rhoton dis-
location of the ACH is often immediately distal and adjacent sector. Use great care to avoid manipulation or dissection of
to the takeoff of the PCOM and needs to be identified and the dome of the aneurysm, as these are often adherent to the
protected with every PCOM aneurysm that is surgically tentorium or the parenchyma at this location. Preclip Doppler
explored and ligated. Although the most common site of origin of the ACH and the PCOM, which is often best done medial
of the ACH is from the ICA itself, normal variants of branch- to the carotid, is of paramount importance, particularly in fetal
ing include origin from the PCOM, the proximal M1, or the PCOM aneurysms.
ICA bifurcation itself. The course of the proximal ACH is Clipping of PCOM aneurysms is typically done with a
posteromedial behind the ICA and is associated with the slightly curved clip, with the proximal blade being placed
medial aspect of the uncus. The second anatomic consideration proximally along the PCOM and at the junction between the
of the PCOM is the presence of a fetal PCOM, whereby the vessel and the aneurysm, visualizing this as much as possible
P1 is functionally absent and as such the fetal PCOM supplies during this maneuver, as well as advancing the distal blade
not only the thalamoperforators along its course but also the between under direct visualization between the PCOM and
ipsilateral P2–P4 segments. By losing the redundancy of the the ACH. The slight curve of the clip helps eliminate a
circle of Willis with this anatomic variant, the importance of “dog-ear” adjacent to the ICA. A final rotation maneuver drop-
preservation of a fetal PCOM becomes the highest priority. ping the surgeon’s hand toward the globe minimizes the likeli-
A transsylvian approach is undertaken in the standard hood that the distal blades will pinch the distal PCOM and
manner with several additional considerations. The PCOM will also make the clip more parallel to the ICA. The ACH
aneurysm can be, and should be assumed to be, adherent to and the distal blades should be inspected immediately. Explo-
the free edge of the tentorium or the medial temporal lobe, ration of the ventral surface of the ICA to ensure a remnant is
Tentorium
Temporal
CN II lobe
ICA
ACoA
PCoA An
A1
M1
M2
M2
Frontal
lobe
• Figure 17.7 A posterior communicating artery (PCOM) aneurysm. The orientation of the PCOM is
shown, originating lateral to the internal carotid artery (ICA), and the coursing posterior and dorsal to the
artery. Distal identification can often be done medial to the ICA. The anterior choroidal should always be
identified before the final dissection of a PCOM aneurysm, as its preservation is paramount. AcoA, anterior
choroidal artery.
not left that is obscured by the ICA is of paramount impor- branch from the M1 supply the deep structures of the anterior
tance. ICGA will identify the distal PCOM and ACH, although perforated substance. Anatomic variants and the configuration
intraoperative angiograms typically produce high-yield results of the bifurcation should be closely studied on preoperative
in PCOM cases, particularly for fetal PCOM aneurysms. imaging.
The exposure and clipping of ACH aneurysms is performed Sylvian fissure dissection needs to be modified for an MCA
in much the same manner as for PCOM aneurysms, with clip bifurcation aneurysm, as the aneurysm can be encountered
selection being dictated by the particular angioarchitecture of with the dissection of the fissure before adequate proximal
the aneurysm. control or brain relaxation/dissection is completed. Preserva-
tion of the superficial temporal artery is generally practiced for
Middle Cerebral Artery Aneurysms MCA lesions, as a bypass can be safely and effectively per-
formed if needed. Generally speaking, one of two strategies for
The middle cerebral artery (MCA) begins after the bifurcation fissure dissection can be used. The first approach of MCA
of the ICA to the M1 and the anterior cerebral artery (ACA). dissection and exposure is a superficial dissection technique,
The M1 segment steeply follows the sphenoid ridge in the base opening the arachnoid over the fissure to begin the exposure
of the Sylvian fissure for a variable length, bifurcating into an of the fissure but working above the anticipated location of the
inferior and superior trunk, the M2 branches. The nature of aneurysm, following the sphenoid ridge proximally to the opti-
this bifurcation is highly variable, with a trifurcation occurring cocarotid cistern in a superficial plane—essentially just opening
in nearly 15% of patients.26 The lenticulostriate vessels that the first layer of the Sylvian fissure. By opening over the optic
nerve in this manner, the opticocarotid cistern is opened and approach are several. It can prematurely expose the aneurysm
CSF is drained, allowing the brain to relax. The ICA can then before adequate proximal control is achieved, it can put the
be explored for a proximal control location, typically at the lenticulostriate vessels at danger if one is careless with dissec-
M1 segment. Once the initial proximal control has been estab- tion, and it can create a narrow corridor of dissection until the
lished, dissection can progress distally along the ICA to the M1 is exposed; as such this deep approach should be used only
bifurcation and the M1, where a preferred temporary clip by more experienced surgeons or for superficial aneurysms.
landing zone should be identified and mentally marked, Regardless of the dissection approach, the importance of
making sure there are no perforators in danger with the M1 opening the fissure widely before beginning the preliminary
temporary clip location, typically as distal as possible on the dissection should be emphasized.
M1 to avoid occlusion of the lenticulostriates. Dissection then Preliminary dissection for MCA aneurysms includes iden-
proceeds distally along the M1 to identify the bifurcation tification of the proximal control point and understanding the
proximal to distal. The second approach for MCA dissection orientation of the aneurysm dome, neck, and parent vessel
and exposure is the deep approach, dissecting beneath the (Fig. 17.8A). With MCA aneurysms this often needs to be
bifurcation and the aneurysm complex to identify the distal correlated with preoperative imaging and mentally adjusted to
M1. Once proximal control is identified, one can then dissect the operative field. Although some MCA aneurysms are easily
through the full depth of the fissure, complete the dissection dissected free from the surrounding parenchyma, many MCA
of the superficial fissure, and expose the aneurysm complex aneurysms often have a small opercular branch, which is adher-
fully. Although this approach works well for aneurysms that ent or obscured on the back side. Lastly, understanding the
are not at the base of the fissure, the pitfalls of this “deep” clip angle and application so that the blades of the clip do not
Tentorium
CN II
CN II
Temporal Temporal
ICA lobe lobe
PCoA PCoA ICA
ACoA
A1 A1
M1 M1
An An
M2 M2
M2
Frontal Frontal
lobe lobe
A B
• Figure 17.8 A middle cerebral artery (MCA) bifurcation aneurysm. (A) The preliminary dissection of an
MCA aneurysm should focus on identification of proximal control (typically a perforator-free zone of the
M1) and the confirmation of the three-dimensional anatomy of the vessels and aneurysm. Determination
of whether the dome needs to be dissected should also be done preliminarily. (B) The second figure in
this series with final dissection of an MCA bifurcation aneurysm and clip placement. Final dissection of
the aneurysm should be done with a provisional clip on standby. Determination of temporary proximal
occlusion should also be done at this juncture as well as final identification of branches immediately at
risk. If micro-Doppler is used, performing a preclip insonation of the distal vessels can be helpful.
cause distal vessel stenosis or occlusion must be carefully

PCoA observed during the clipping, and because of the complexity
of many MCA aneurysms, a multitude of clip constructs may
ACoA
be possible. Generally, placing the clip and addressing the
ICA distal neck of the aneurysm allows additional clips to be placed
more proximally to complete the clipping. Surgeons should
avoid the temptation to have a single clip reconstruct anything
but the most straightforward aneurysm. As noted previously,
calcification with MCA aneurysms is common and can chal-
lenge even the most skilled surgeon. Because of the full expo-
A1 M1 sure of these aneurysms, once one of them has been clipped,
explored, and insonated with a Doppler, indocyanine green
videoangiography and intraoperative angiography will docu-
ment complete obliteration and preservation of the normal
An
vasculature.
Anterior Communicating Artery Aneurysms

Selecting the side of approach to ACOMM aneurysms deserves
attention, as they can typically be approached from either the
M2 M2 left or the right. Dominance of the A1 and overall orientation
of the complex can favor one side over the other, as well as the
surgeon’s preference. For elective cases, some advocate a right-
sided approach unless there are clear reasons to approach from
the contralateral side because of the eloquence of the left
hemisphere. The transsylvian approach and fissure dissection
is performed in a similar manner for ACOMM aneurysms as
other approaches, and an ultimate lateral-to-medial trajectory
is preferred. Once the opticocarotid cistern is identified and
opened, the ICA is then followed posteriorly to the ICA bifur-
C cation. After the bifurcation of the MCA and the ACA, the
• Figure 17.8, cont’d (C) The clipped aneurysm. A1 branch travels medially and somewhat anteriorly to the
ACOMM complex. From there, also supplied by the contra-
lateral A1 and through the communicating artery, the most
ventral aspect of the circle of Willis, the vessels then move
distally as paired A2. Complete dissection of the ACOMM
compromise the origin of the M2 branches is of utmost complex requires the identification of 12 named vessels: paired
importance. A1 and A2 segments, ipsilateral and contralateral recurrent
The final dissection around the MCA aneurysm should be arteries of Heubner, and the communicating segment itself.14
done sharply (Fig. 17.8B). Because of the ease of temporary Other branches include the associated A1 perforators and the
clip placement with these lesions, we often occlude them tem- bilateral orbitofrontal and frontal polar arteries, but they are
porarily to soften the dome and complete the dissection. MCA infrequently involved by the aneurysm. Identification of the
aneurysms often have broad necks, and not infrequently they first seven is of great importance in every case. The identifica-
incorporate the neck or sac into one of the distal vessels at the tion of the recurrent artery of Heubner can be challenging and
neck, giving the appearance of a broader-still neck. The impor- is typically medially to laterally oriented from the distal A1.
tance of identifying the actual neck is that it will allow an Not uncommonly, the origin is proximal A2 or the communi-
accurate clipping of the aneurysm but also will minimize the cating segment itself, but as a rule of thumb, it is almost always
folding of normal parent artery into the clip construct. Doppler identified immediately adjacent to the ACOMM. Second, the
of the M2 branches and associated smaller branches should perforators from the distal A1 and the ACOMM should be
always be performed. preserved, and they are a potential source of significant mor-
The clipping of an MCA aneurysm should be done in the bidity associated with the treatment of ACOMM aneurysms.
same manner as others with several nuances. Because of the Once the A1 has been identified above the optic nerve, the
aforementioned broad neck that is commonly encountered, first provisional proximal temporary clip landing zone is iden-
stenosis of the parent vessel after clipping can be monitored by tified. Before dissecting further, the arachnoid that is ventral
clipping a softened aneurysm with a clip slightly higher than to the frontal lobe is also divided with the goal of identifying
usual so that as it closes it will incorporate the neck and recon- the contralateral optic nerve and allowing the frontal lobe to
struct the parent vessel. Torsion of clip constructs that can fall away from the skull base, using gravity to aid in retraction.
Preliminary dissection then proceeds along the A1, dividing temporary clip on the contralateral A1. It is tempting at this
additional arachnoid membranes along the length. Depending time to move forward with further dissection, but both recur-
on the trajectory of the ACOMM aneurysm, a number of rent arteries of Heubner must be identified if at all possible.
decisions have to be made at this point (Fig. 17.9A). In com- Regardless, during this preliminary dissection, following the
parison to MCA aneurysms where one has almost certain ipsilateral A1 cephalad within the interhemispheric fissure to
access to all branches at this juncture, the dissection before the A2 is now done. Again, depending on the orientation of
clipping does not necessarily reveal all afferent and efferent the aneurysm, the contralateral A2 may also be visualized
vessels. Preoperative planning and understanding of the orien- above the aneurysm complex at this site. Although ultimate
tation and the expectation of which vessels may be obscured identification is necessary, not all branches may be identified
will be helpful. To add to the challenges of ACOMM aneu- prior to clip application. Typically, either the contralateral A1
rysms, there is almost invariably a rotational component to the or the contralateral A2 can be identified prior to final dissec-
complex, often dictated by the dominant artery and the flow tion; often both cannot. Lesions that are pointed anterior or
trajectory.27 There are a multitude of variables that will cause inferior are much more straightforward for these reasons.
significant variations, and the surgeon should be comfortable Resection of the gyrus rectus should be undertaken only if
with the 3D interpretation of the preoperative imaging to necessary and with care and consideration to what is to be
facilitate final anatomic identification. Aneurysms that are gained. This is most often necessary for aneurysms pointing
pointing superiorly or posteriorly will allow the dissection to posteriorly. The gyrus rectus is identified immediately medial
be carried beneath the complex to the contralateral A1 and to the olfactory tract and is best resected using a microdissector
recurrent artery of Heubner, thereby identifying the paired A1, and suction technique to efficiently remove this, leaving the
paired recurrent arteries, and ipsilateral A2 at a minimum. This arachnoid of the interhemispheric fissure overlying the vessels
also allows a contralateral provisional landing zone for a in place. This arachnoid is then opened deliberately using great
Frontal
Frontal CN II lobe CN II
lobe RAH
A1 A1
A2
CN II CN II
An
A2 ACoA
RAH
A1 ICA A1 ICA
Aneurysm
neck
M1 M1
A B
• Figure 17.9 Anterior communicating aneurysm. (A) Preliminary dissection of an ACOMM aneurysm
should focus on proper orientation of the aneurysm and identification of the contralateral A1 for proximal
control, and ipsilateral A1 and A2. (B) Final dissection of an ACOMM complex with base and neck well
exposed, and potentially contralateral A2 and recurrent artery of Heubner identified. The final dissection
of an ACOMM aneurysm should focus on final delineation of the neck and dissection of adherent vessels,
as well as identification of contralateral vessels. Occasionally, because of the size or morphology of the
aneurysm, definitive identification of the distal vessels cannot be done until after the aneurysm is clipped.
Some surgeons will opt to place a proximal contralateral A1 clip during final dissection.
hemorrhage during the final dissection or clip application,

then safe identification of the contralateral A1 can oftentimes
RAH be challenging. With downward or anterior-directed aneu-
rysms, temporary clipping of the contralateral A1 can be more
challenging but is less often necessary.
Clip application of the ACOMM can be challenging
because of the narrow corridor one is working with, as
well as accounting for the invariable rotational component of
A2 ACOMM aneurysm complexes. Also, as noted, the final dis-
A1
section and visualization of vessels with these lesions will some-
times occur late during the clipping process. Maintaining the
clip blades parallel with the communicator minimizes rem-
nants and torque on the complex and lessens potential injury
to perforators (Fig. 17.9C). Using the blades as microretractors
An during the clipping process maximizes the corridors visualized
during clipping. ACOMM aneurysms that point posteriorly
typically require the use of fenestrated clips, with the fenestra-
A2 tion encompassing the ipsilateral A2 and the blades avoiding
ACoA
compromise of the contralateral A1–A2 junction. The contra-
lateral A2, then the contralateral A1 and the recurrent artery
of Heubner, the communicating artery perforators, and then
the ipsilateral vessels should be visualized during the final clip-
RAH
ping and manipulation process. Insonation of the major vessels
A1 with a micro-Doppler and identification of the branches listed
earlier are then completed after the aneurysm is secure. ICGA
can be useful for identifying flow, in particular in the recurrent
artery of Heubner and the contralateral A2. Intraoperative
angiograms are high yield for ACOMM aneurysms in our
experience.28
C Pericallosal Aneurysms
• Figure 17.9, cont’d (C) Status postclipping showing distal vessels
and exploration of the aneurysm. Immediately after clipping, the proximal The pericallosal artery begins as A2 segments from the com-
and distal vessels should be visually inspected. municating segment, branching to A3 at the rostrum of the
corpus callosum, and then to A4 in the horizontal segment;
distal branches are A5 and are infrequently involved. The bifur-
care to preserve the perforators and the recurrent artery of cation of the pericallosal artery, the arterial branch that courses
Heubner, which lie immediately beneath it. This maneuver along the corpus callosum, and the callosomarginal artery,
typically exposes the ipsilateral A1 and both A2s. While avoid- which courses along the cingulate sulcus, is the most common
ing dissecting the neck during this preliminary dissection stage, location of pericallosal aneurysms, but both the native arte-
a clear understanding and localization of the contralateral A2, rial anatomy and the location of aneurysms are highly vari-
when possible, is important, as the junction between this and able. For this reason, dissection and arterial dissection can be
the contralateral A1/A2/communicatory segment is important challenging.
for successful and safe clipping of an ACOMM aneurysm. This Differing from the remaining aneurysms of the anterior
technique of localization of the contralateral A2 above the circulation that can be addressed by a transsylvian approach
complex can be used even for superior projecting aneurysms using either a pterional or orbitozygomatic approach, perical-
that often obscure this vessel. losal aneurysms are usually accessed with the interhemispheric
During this final phase, we generally begin by identifying approach. Because the prepared distal anterior cerebral arteries
the perforators at risk, in particular along the posterior aspect are intimately associated with each other within the interhemi-
of the communicating artery, and then focusing on first the spheric fissure, the overwhelming majority of pericallosal aneu-
contralateral neck and then the ipsilateral neck (Fig. 17.9B). rysms can be approached from the right side. Patient positioning
At this phase, if the contralateral A1 can be identified and the is counterintuitive, with the head in a lateral position and the
recurrent artery of Heubner can be safely avoided, consider- right side of the head down to use gravity to allow the frontal
ation of a contralateral temporary clip can be entertained. By lobe to fall away from the falx. The head is parallel to the floor
placing the temporary clip out of the field of direct dissection, with the vertex angled upward so that the surgeon has a direct
one has typically more straightforward access to the ipsilateral view down the corridor of the falx. Pericallosal aneurysms can
A1 for temporary clipping if needed, whereas if one has occasionally benefit from stereotactic navigation for the novice
surgeon, as this can facilitate the trajectory of the approach and minimized whenever possible during the approach. Following
general location of the aneurysm. In general, the craniotomy the pericallosal arteries proximally will identify the distal A2
is placed two-thirds anterior to the coronal suture and one- segment, just prior to the bifurcation of the pericallosal and
third behind, with a rectangular craniotomy extending over the callosomarginal arteries, the most common location for these
superior sagittal sinus. The importance of being on, rather than aneurysms. This is an ideal site for proximal control and should
adjacent to, the sinus should be emphasized, as the surgeon be evaluated to confirm that this is indeed the affected vessel,
should be able to open the dura to the sinus and have a trajec- not its contralateral counterpart. Working more proximally
tory that allows a view down the falx; angles away from this than this on the A2 is challenging because of the depth and
trajectory will significantly limit deep views and, importantly, angle of the field; as such, a frontal approach is favored for
increase the need for retractors. The positioning of this crani- these more proximal aneurysms.
otomy can be adjusted, but the emphasis of the forward posi- The final dissection involves identification of the proximal
tioning of the craniotomy and the forward, deep surgical and distal ipsilateral vessels (Figs. 17.10 and 17.11). It is not
trajectory is the most common pitfall of the initial approach. uncommon to have several vessels adherent to the aneurysm
We prefer a relatively large craniotomy to select a trajectory complex that need to be ultimately dissected and preserved.
that avoids injury to any of the bridging veins to the superior Similar to ACOMM aneurysms, having a three-dimensional
sagittal sinus. Thrombosis or injury to the draining veins from image of the ipsilateral and contralateral vessels is important.
the frontal lobe to the superior sagittal sinus can be devastat- We find that if the contralateral vessels can be exposed and
ing. All attempts should be made to protect them and work freed during this dissection, a patty or wisp of cotton can be
around them. We usually place a piece of Gelfoam soaked in placed over the contralateral vessels to effectively isolate them
heparin on the larger veins to prevent thrombosis. The heparin out of the immediate field. Preoperative imaging can often
is absorbed through the venous wall, providing local antico- allow the surgeon to appreciate the exact location of the neck,
agulation. The initial approach and dissection through the so that dome dissection can be minimized. Before clipping,
subdural space proceeds to the corpus callosum, and the paired with pericallosal aneurysms there is often adequate room for a
pericallosal arteries are identified. temporary clip, and this can facilitate the final dissection,
The preliminary dissection follows the pericallosal arteries which is often challenging because of the depth of the field
proximally toward the rostrum of the corpus callosum (Fig. and surgeon’s orientation, which is often overhead angle.
17.10). The use of cotton balls moving forward can provide Invariably, there is an early branch that should be identified
focal retraction as necessary. This dissection can be perilous and dissected if necessary. Doppler pre- and postclipping of
with ruptured aneurysms, as the clot or dome may be adherent both ipsi- and contralateral vessels will allow immediate feed-
to the brain surface; as such, over distraction should be back of distal occlusions, and ICGA and intraoperative DSA
Falx PcaA SSS

SSS
CC
An
PcaA
• Figure 17.10 Positioning of a pericallosal aneurysm. The counterintuitive positioning of a midline

pericallosal aneurysm, with the pathologic side on the downward hemisphere. By using gravity to assist
with retraction, the exposure is facilitated.
LPcaA
CC
An
RPcaA
• Figure 17.11 Pericallosal aneurysm. The A3 branches should be followed proximally, ensuring that
the appropriate vessels have been identified. Because of individual anatomy, identification of bilateral
vessels can ensure that one does not follow the incorrect vessel to the aneurysm. Although not often
done, stereotactic navigation can be useful to identify the correct trajectory. Following the corpus callosum
around the genu can often identify the proximal vessel. After clipping, often with a fenestrated clip, the
distal branches are frequently at risk with these lesions. Confirming adequate distal flow is paramount.
will confirm complete obliteration of the aneurysm and normal Kassell NF, Torner JC, Haley EC Jr, et al. The International Cooperative
filling of the surrounding vasculature. Study on the Timing of Aneurysm Surgery. Part 1: Overall manage-
ment results. J Neurosurg. 1990;73(1):18-36.
Lawton MT. Seven Aneurysms: Tenets and Techniques for Clipping. New
York: Thieme Medical Publishers; 2010.
Selected Key References Menghini VV, Brown RD Jr, Sicks JD, et al. Clinical manifestations and
survival rates among patients with saccular intracranial aneurysms:
Bouthillier A, van Loveren HR, Keller JT. Segments of the internal population-based study in Olmsted County, Minnesota, 1965 to
carotid artery: a new classification. Neurosurgery. 1996;38(3):425-432, 1995. Neurosurgery. 2001;49(2):251-256, discussion 256-8.
discussion 432-3. Osborne AG. Diagnostic Cerebral Angiography. 2nd ed. Philadelphia:
Day AL. Aneurysms of the ophthalmic segment. A clinical and anatomi- Lippincott Williams & Wilkins, Wolters Kluwer; 1999.
cal analysis. J Neurosurg. 1990;72(5):677-691. Rhoton AL Jr, Perlmutter D. Microsurgical anatomy of anterior com-
Dean BL, Wallace RC, Zabramski JM, et al. Incidence of superficial municating artery aneurysms. Neurol Res. 1980;2(3-4):217-251.
sylvian vein compromise and postoperative effects on CT imaging Schievink WI. Genetics and aneurysm formation. Neurosurg Clin N Am.
after surgical clipping of middle cerebral artery aneurysms. AJNR Am 1998;9(3):485-495.
J Neuroradiol. 2005;26(8):2019-2026. Tang G, Cawley CM, Dion JE, et al. Intraoperative angiography during
International Study of Unruptured Intracranial Aneurysms Investigators. aneurysm surgery: a prospective evaluation of efficacy. J Neurosurg.
Unruptured intracranial aneurysms–risk of rupture and risks of surgi- 2002;96(6):993-999.
cal intervention. N Engl J Med. 1998;339(24):1725-1733. Please go to ExpertConsult.com to view the complete list of references.
CHAPTER 17 Anterior Circulation Aneurysms 281.e1
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8. Kassell NF, Torner JC, Haley EC Jr, et al. The International Coop- 22. Dean BL, Wallace RC, Zabramski JM, et al. Incidence of superficial
erative Study on the Timing of Aneurysm Surgery. Part 1: Overall sylvian vein compromise and postoperative effects on CT imaging
management results. J Neurosurg. 1990;73(1):18-36. after surgical clipping of middle cerebral artery aneurysms. AJNR
9. Menghini VV, Brown RD Jr, Sicks JD, et al. Clinical manifesta- Am J Neuroradiol. 2005;26(8):2019-2026.
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aneurysms with helical CT: correlation with conventional angiogra- the middle cerebral artery. J Neurosurg. 1981;54(2):151-169.
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12. Osborne AG. Diagnostic Cerebral Angiography. 2nd ed. Philadelphia: communicating artery aneurysms. Neurol Res. 1980;2(3-4):217-251.
Lippincott Williams & Wilkins, Wolters Kluwer; 1999. 28. Tang G, Cawley CM, Dion JE, et al. Intraoperative angiography
13. Bouthillier A, van Loveren HR, Keller JT. Segments of the internal during aneurysm surgery: a prospective evaluation of efficacy. J
carotid artery: a new classification. Neurosurgery. 1996;38(3):425- Neurosurg. 2002;96(6):993-999.
432, discussion 432-3.
14. Lawton MT. Seven Aneurysms: Tenets and Techniques for Clipping.
New York: Thieme Medical Publishers; 2010.

17 Anterior Circulation Aneurysms

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Vascular Neurosurgery

Introduction magnetic resonance imaging (MRI), which are performed for

Prefrontal sulcal A PPBr

In addition, although the presence of a hematoma or subarach-

and it lies immediately adjacent to the opticocarotid triangle,

cause distal vessel stenosis or occlusion must be carefully

Anterior Communicating Artery Aneurysms

hemorrhage during the final dissection or clip application,

Falx PcaA SSS

• Figure 17.10 Positioning of a pericallosal aneurysm. The counterintuitive positioning of a midline

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