Volume 92, Pages 313-322 (August 2016) Presigmoid Approach to Vertebrobasilar Artery Aneurysms: A Series of 31 Patients and Review of the Literature

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Volume 92, Pages 313-322 (August 2016) Presigmoid Approach to Vertebrobasilar Artery Aneurysms: A Series of 31 Patients and Review of the Literature Mardjono Tjahjadi, Mika Niemelä, Juri Kivelev, Joseph Serrone, Hidetsugu Maekawa, Behnam Rezai Jahromi, Oleg Kerro, Ahmad Hafez, Hanna Lehto, Riku Kivisaari, Juha Hernesniemi World Neurosurgery Volume 92, Pages 313-322 (August 2016) DOI: 10.1016/j.wneu.2016.05.001 Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 1 Steps of the presigmoid approach to clip a basilar tip aneurysm. (A) Skin incision marking. (B) The exposure after the craniotomy and temporal bone drilling. (C) Opening the dura mater and cutting the superior petrosal sinus (SPS). (D) The tentorium (Tent) is cut toward its edge with preservation of the fourth nerve. (E) Aneurysm exposure with its surrounding neurovascular anatomy. (F) Proximal temporary clip of basilar artery (BA). (G) Distal temporary clip of left posterior communicating artery (Lt PCom). (H) Neck clip application. (I) Definitive tandem clip application. III, oculomotor nerve; IV, trochlear nerve; An, aneurysm; Lt P1, left posterior cerebral artery segment 1; Lt P2: left posterior cerebral artery segment 2; Lt SCA, left superior cerebellar artery; SDA, sinodural angle; SPS, superior petrosal sinus; SS, sigmoid sinus; TLD, temporal lobe dura. World Neurosurgery 2016 92, 313-322DOI: (10.1016/j.wneu.2016.05.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 2 The postoperative computed tomographic bone reconstruction showed the area of craniotomy and temporal bone drilling. The minimal bone drilling allows the surgery to be faster and safer (yellow arrows). Red arrow, the inner ear structures that were left intact. World Neurosurgery 2016 92, 313-322DOI: (10.1016/j.wneu.2016.05.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 3 The location of basilar artery aneurysms that were clipped using our modified presigmoid approach. AICA, anterior inferior cerebellar artery; SCA, superior cerebellar artery; VA, vertebral artery; VBJ, vertebrobasilar junction. World Neurosurgery 2016 92, 313-322DOI: (10.1016/j.wneu.2016.05.001) Copyright © 2016 Elsevier Inc. Terms and Conditions

Figure 4 (A1, A2) Pre- and postoperative result of complete clipping of a large proximal basilar trunk aneurysm. (B1, B2) Pre- and postoperative result of the neck residual of the medium-sized basilar tip aneurysm; some part of the neck remnant is still seen on the postoperative angiogram (yellow arrow). (C1, C2). Pre- and postoperative image of both basilar-superior cerebellar artery and fenestrated vertebrobasilar junction aneurysm. The basilar-superior cerebellar artery aneurysm is completely clipped, but there is a small neck and fundus remnant of the fenestrated vertebrobasilar junction aneurysm (yellow arrow). World Neurosurgery 2016 92, 313-322DOI: (10.1016/j.wneu.2016.05.001) Copyright © 2016 Elsevier Inc. Terms and Conditions