J Korean Neurosurg Soc.  2017 Feb;60(2):250-256. 10.3340/jkns.2016.0910.009.

Pterional or Subfrontal Access for Proximal Vascular Control in Anterior Interhemispheric Approach for Ruptured Pericallosal Artery Aneurysms at Risk of Premature Rupture

• Park J

• KMID: 2374888
• DOI: http://doi.org/10.3340/jkns.2016.0910.009

Abstract

OBJECTIVE
Cases of a ruptured pericallosal artery aneurysm with a high risk of intraoperative premature rupture and technical difficulties for proximal vascular control require a technique for the early and safe establishment of proximal vascular control.
METHODS
A combined pterional or subfrontal approach exposes the bilateral A1 segments or the origin of the ipsilateral A2 segment of the anterior cerebral artery (ACA) for proximal vascular control. Proximal control far from the ruptured aneurysm facilitates tentative clipping of the rupture point of the aneurysm without a catastrophic premature rupture. The proximal control is then switched to the pericallosal artery just proximal to the aneurysm and its intermittent clipping facilitates complete aneurysm dissection and neck clipping.
RESULTS
Three such cases are reported: a ruptured pericallosal artery aneurysm with a contained leak of the contrast from the proximal side of the aneurysm, a low-lying ruptured pericallosal artery aneurysm with irregularities on its proximal wall, and a multilobulated ruptured pericallosal artery aneurysm with the parasagittal bridging veins hindering surgical access to the proximal parent artery. In each case, the proposed combined pterional-interhemispheric or subfrontal-interhemispheric approach was successfully performed to establish proximal vascular control far from the ruptured aneurysm and facilitated aneurysm clipping via the interhemispheric approach.
CONCLUSION
When using an anterior interhemispheric approach for a ruptured pericallosal artery aneurysm with a high risk of premature rupture, a pterional or subfrontal approach can be combined to establish early proximal vascular control at the bilateral A1 segments or the origin of the A2 segment.

Keyword

Clipping; Interhemispheric approach; Intracranial aneurysms; Proximal vascular control; Pterional approach

MeSH Terms

Aneurysm*
Aneurysm, Ruptured
Anterior Cerebral Artery
Arteries*
Humans
Intracranial Aneurysm
Neck
Parents
Rupture*
Veins

Figure

• 

  Fig. 1 Illustrations depicting the combination of a pterional or subfrontal approach and interhemispheric approach. A: Combined pterional-paramedian craniotomy for a pterional-interhemispheric approach. The dural opening (dotted line) creates a C-shaped dural flap based anteriorly and another dural flap based medially along the superior sagittal sinus. B: Frontal craniotomy bordered by the lateral orbital roof and a superior sagittal sinus for a combined subfrontal-interhemispheric approach. C: Alternation between a pterional approach and anterior interhemispheric approach.

• 

  Fig. 2 Case 1. A: Coronal image of the CTA revealing contrast extravasation (arrows) from a ruptured pericallosal artery aneurysm. B: Sagittal image of the CTA revealing contrast extravasation (arrow) from the ruptured pericallosal artery aneurysm. C: DSA revealing severe stenosis (arrow) of the parent artery and a wide neck of the pericallosal artery aneurysm. D: Intraoperative photographs of the combined pterional-interhemispheric approach. Note the left insert, showing the clipped pericallosal artery aneurysm via the anterior interhemispheric approach, and the right insert, showing the temporary clip applied to the origin of the ipsilateral A2 segment via the pterional approach. E: Postoperative CTA demonstrating complete aneurysmal clipping without compromise of the parent artery. F: Postoperative CT of the head showing the combined pterional-paramedian craniotomy. CTA: computed tomography angiography, DSA: digital subtraction angiography.

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  Fig. 3 Case 2. A: DSA showing a ruptured pericallosal artery aneurysm arising from the origin of the callosomarginal artery. B: Sagittal image of the CTA revealing a low-lying pericallosal artery aneurysm as low as 14 mm from the level of the planum sphenoidale. C: Intraoperative photograph showing the frontal craniotomy for the subfrontal-interhemispheric approach. D: Intraoperative photograph showing the cranial bone flap fixed in place after clipping the aneurysm. The craniotomy is bordered by the lateral orbital roof and a superior sagittal sinus. E: Intraoperative photograph showing the bilateral A1 segments via the subfrontal approach. A temporary clip is applied to the contralateral A1 segment. F: Intraoperative photograph showing the pericallosal artery aneurysm clipping via the interhemispheric approach. G: Postoperative CTA demonstrating complete aneurysmal clipping without compromise of the parent artery. DSA: digital subtraction angiography, CTA: computed tomography angiography.

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  Fig. 4 Case 3. A: DSA showing a left pericallosal artery aneurysm arising from the origin of the callosomarginal artery. B: Venous phase of the left carotid angiogram showing parasagittal bridging veins hindering surgical access to the proximal parent artery via an interhemispheric approach. C: Intraoperative photograph showing bilateral A1 segments via a pterional approach. A temporary clip is applied to the contralateral A1 segment. D: Intraoperative photograph showing the anterior interhemispheric approach. E: Intraoperative photograph showing aneurysm clipping via the anterior interhemispheric approach. F: Postoperative CTA demonstrating complete clipping of the pericallosal artery aneurysm and MCA aneurysm. G: Postoperative CT of the head showing the combined pterional-paramedian craniotomy. DSA: digital subtraction angiography, CTA: computed tomography angiography, MCA: middle cerebral artery.

Reference

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