Abstract
We introduce a less‒invasive surgical strategy for elderly patients with a poor‒grade subarachnoid hemorrhage (SAH) with casting intraventricular hemorrhage (IVH) due to a large ruptured aneurysm located in the anterior communicating artery (ACA). In this strategy, a small‒area frontal craniotomy is conducted around Kocher’s point, and a ventricular drainage tube is inserted into the anterior horn of the lateral ventricle. After direct microscope‒guided evacuation of the IVH using the ventricular drainage tube, dome clipping of the aneurysm including the ruptured point is performed by a transventricular approach. Although we have focused on a reliable closure of the rupture point in cases of poor‒grade SAH with casting IVH, the complete clipping of the aneurysm is not considered very important. A prompt improvement of the pathophysiology that provided the conditions for the patient’s deterioration is necessary; i. e., the release of the increased intracranial pressure by removal of the IVH. The patient outcomes depend on the degree of primary brain damage, and thus a favorable functional recovery can be expected only if the primary brain damage was limited and a new secondary injury was avoided. Although an interhemispheric approach has often been used in patients with a large or high‒positioned aneurysm in the ACA, that procedure has a clinical disadvantage (i. e., the invasiveness involved in the opening of the frontal sinus), and the surgical manipulation presents a significant amount of time and difficulty. The surgical approach we describe herein is less invasive and takes less time as it is not necessary to open the frontal sinus and dissect the interhemispheric fissure, making it possible to improve the pathophysiology with direct IVH evacuation and prevent re‒rupture of the aneurysm. It is also important to determine both the relevant surgical indications and whether it is possible to deal with an aneurysm safely using the transventricular approach, by considering the patient’s preoperative neurological images.
