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Tomoya Kamide, Halima Tabani, Michael M. Safaee, Jan-Karl Burkhardt, and Michael T. Lawton

with optic nerve decompression. Fig. 2 Illustrative case 2. This 53-year-old woman presented with vision loss in her left eye and was diagnosed with a 6.8 × 9.5–mm unruptured left OphA aneurysm ( A–C ). Due to the presenting symptoms with compression of the left optic nerve, microsurgical clipping and decompression of the optic nerve was indicated. After an extradural anterior clinoidectomy the dura was opened and the sylvian fissure widely split using microsurgical technique. The dura over the clinoid region was opened to allow communication between the intradural

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Lukas Goertz, Christina Hamisch, Christoph Kabbasch, Jan Borggrefe, Marion Hof, Anna-Katharina Dempfle, Moritz Lenschow, Pantelis Stavrinou, Marco Timmer, Gerrit Brinker, Roland Goldbrunner, and Boris Krischek

A lthough the techniques of endovascular treatment have evolved significantly in the last 2 decades, microsurgical clipping still represents a safe and effective treatment option for intracranial aneurysms, in particular for aneurysms with complex morphology. Cerebral infarction is a potential complication of surgical aneurysm therapy, with an observed frequency between 0.9% and 45.3%. 4 , 12 , 23 , 24 The reasons for infarction include lengthy temporary clipping of the parent artery, occlusion of perforating arteries by improper clip placement, and excessive

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Puay-Yong Ng, Daniel Huddle, Murat Gunel, and Issam A. Awad

endovascular balloon failed, and in one instance the method was successfully used on an emergency basis after intraoperative rupture of a small OA aneurysm in which the cervical ICA was not exposed (unpublished data). After favorable experiences in each of these early cases, the procedure was subsequently applied prospectively in 24 consecutive cases based on consistent inclusion and exclusion criteria, and without routine cervical ICA exposure. We hypothesize that this method is feasible and safe when applied routinely, and facilitates microsurgical clipping of large

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Piyush Kalakoti, Richard D. Murray, Shyamal C. Bir, Osama Ahmed, and Anil Nanda

With the advent of endovascular modalities, endovascular coiling has become a progressively more common method of addressing intracranial aneurysms. When despite coiling, an aneurysm continues to enlarge, open microsurgical clipping is a viable, though technically demanding option. We present a unique case of failed coiling of a giant ophthalmic region aneurysm, in which the aneurysm was successfully managed via open microsurgical approach. We highlight the unique challenges faced and demonstrate the surgical process in an operative video presentation.

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Ulas Cıkla, Kutluay Uluç, and Mustafa K. Baskaya

Giant posterior circulation aneurysms pose a significant challenge to neurovascular surgeons. Among various treatment methods that have been applied individually or in combination, clipping under hypothermic circulatory arrest (HCA) is rarely used. We present a 62-year-old man who initially underwent coil occlusion of the right vertebral artery (VA) for a 2.5 cm giant vertebrobasilar junction (VBJ) aneurysm. His neurological condition had declined gradually and the aneurysm grew to 4 cm in size. The patient underwent clip reconstruction of giant VBJ aneurysm under HCA. His postoperative course was prolonged due to his preexisting neurological deficits. His preoperative Modified Rankin Score was 5, and improved postoperatively to 3 at three and six months, and to 2 at one year.

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M. Yashar S. Kalani, Mark E. Oppenlander, Michael Levitt, Sam Safavi-Abbasi, Robert F. Spetzler, and Joseph M. Zabramski

Unruptured posterior circulation aneurysms pose a treatment challenge. Although data supports the use of endovascular technique for select ruptured cases, in unruptured cases, there may be clinical equipoise. Furthermore, wide-necked basilar apex aneurysms commonly require the use of stents and placement of patients on dual therapy. We present a case of a healthy 50-year-old woman with an incidental basilar tip aneurysm treated via an orbitozygomatic craniotomy. This video highlights the steps of dynamic retraction, which is retraction without placement of permanent rigid retraction system, and the added maneuverability afforded by the use of the mouthpiece on the microscope.

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Justin M. Caplan, Eric Sankey, David Gullotti, Joanna Wang, Erick Westbroek, Brian Hwang, and Judy Huang

Patients with bilateral anterior circulation aneurysms present a management challenge. These lesions may be treated in a staged manner or alternatively, for select patients, a contralateral approach may be utilized to treat bilateral aneurysms with a single surgery. In this narrated video illustration, we present the case of a 57-year-old woman with incidentally discovered bilateral aneurysms (left middle cerebral artery [MCA], left anterior choroidal artery and right MCA). A contralateral approach through a left pterional craniotomy was performed formicrosurgical clipping of all three aneurysms. The techniques of pterional craniotomy, contralateral approach, microsurgical clipping and intraoperative angiography are reviewed.

The authors are grateful to Wuyang Yang, M.D. for his assistance.

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Joan Margaret O’Donnell, Michael Kerin Morgan, and Maurizio Manuguerra


Few studies have examined patients’ ability to drive and quality of life (QOL) after microsurgical repair for unruptured intracranial aneurysms (uIAs). However, without a strong evidentiary basis, jurisdictional road transport authorities have recommended driving restrictions following brain surgery. In the present study, authors examined the outcomes of the microsurgical repair of uIAs by measuring patients’ perceived QOL and cognitive abilities related to driving.


Between January 2011 and January 2016, patients with a new diagnosis of uIA were prospectively enrolled in this study. Assessments were performed at referral, before surgery, and at 6 weeks and 12 months after surgery in those undergoing microsurgical repair and at referral and at 12 months in conservatively managed patients. Assessments included the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36, the off-road driver-screening instrument DriveSafe (DS), the modified Barthel Index (mBI), and the modified Rankin Scale (mRS).


One hundred sixty-nine patients were enrolled in and completed the study, and 112 (66%) of them had microsurgical repair of their aneurysm. In the microsurgical group, there was a trend for improved DS scores: from a mean (± standard deviation) score of 108 ± 10.7 before surgery to 111 ± 9.7 at 6 weeks after surgery to 112 ± 10.2 at 12 months after surgery (p = 0.05). Two percent of the microsurgical repair group and 4% of the conservatively managed group whose initial scores indicated competency to drive according to the DS test subsequently had 12-month scores deemed as not competent to drive; the difference between these 2 groups was not statistically significant (p > 0.99). Factors associated with a decline in the DS score among those who had a license at the time of initial assessment were an increasing age (p < 0.01) and mRS score > 0 at one of the assessments (initial, 6 weeks, or 12 months; p < 0.01).

Mean PCS scores in the microsurgical repair group were 52 ± 8.1, 46 ± 6.8, and 52 ± 7.1 at the initial, 6-week, and 12-month assessments, respectively (p < 0.01). These values represented a significant decline in the mean PCS score at 6 weeks that recovered by 12 months (p < 0.01). There were no significant changes in the MCS, mBI, or mRS scores in the surgical group.


Overall, QOL at 12 months for the microsurgical repair group had not decreased and was comparable to that in the conservatively managed group. Furthermore, as assessed by the DS test, the majority of patients were not affected in their ability to drive.

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Pedram Golnari, Pouya Nazari, Roxanna M. Garcia, Hannah Weiss, Ali Shaibani, Michael C. Hurley, Sameer A. Ansari, Matthew B. Potts, and Babak S. Jahromi

T he International Subarachnoid Aneurysm Trial (ISAT) 26 compared mortality and clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (SAH) following either endovascular treatment (EVT) or microsurgical clipping. Published in 2002, the ISAT reported an absolute risk reduction of 6.9% of death or dependence at 1 year favoring EVT for ruptured aneurysms. Analogous results were published a year later for unruptured aneurysms when the International Study of Unruptured Intracranial Aneurysms (ISUIA), 45 a nonrandomized prospective study, reported

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Michael A. Silva, Alfred P. See, Hormuzdiyar H. Dasenbrock, Nirav J. Patel, and Mohammad A. Aziz-Sultan

terms, with Medical Subject Headings (MeSH) and title/abstract (tiab) as qualifiers. Studies were considered for inclusion if they reported on either unruptured paraclinoid aneurysms or subarachnoid hemorrhage from a paraclinoid aneurysm causing visual symptoms and treated with microsurgical clipping, coil embolization, or FD. The abstracts were screened by 2 authors (M.A.S. and A.P.S.), and any discrepancies were settled by discussion. Editorials, abstracts alone, reviews, case reports, articles not in English, and articles only reporting the natural history of