The most significant surgical complication with vertebral artery aneurysms located at or close to the midline is retraction damage to the VIIth to XIIth cranial nerves. From our experience with three patients, we have found the best surgical approach to minimize the cranial nerve injury. The location of the aneurysms related to the jugular tubercle was an important factor for selection of the surgical approach. The procedures we recommend are described below. For aneurysms which are located higher than the level of the jugular tubercle, a posterior transpetrosal approach should be adopted. A lateral suboccipital approach should offer sufficient surgical space for aneurysms which are located on or lower than the level of the jugular tubercle by removal of the jugular tubercle or occipital condyle (transcondyle approach). A transoral transclival approach might be indicated for aneurysms located lower than the level of the jugular tubercle
