Between September 1992 and December 1994, 166 patients with intracranial aneurysms were admitted to our hospital and underwent microsurgical operations. Of the 166 patients, 8 had the midline vertebral artery aneurysms. Of these 8 cases, 4 were VA-PICA aneurysms, 3 VA-dissecting aneurysms and 1 a VA-BA junction aneurysm.
On the A-P view of the vertebral angiograms, the VA-PICA aneurysms were located between 2.5mm and 8mm from the midline. On the lateral view, the aneurysm necks were located 9-14 mm from the internal auditory meatus.
We applied the lateral suboccipital transcondylar approach to these midline vertebral aneurysms. Surgical procedures are as follows: (1) the patient is placed in the lateral position with the head kept in the maximal flexion; (2) the following structures are exposed and removed; the ipsilateral suboccipital bone, the condylar fossa, the posterior one-third of the occipital condyle, the dorsolateral rim of the foramen magnum and the ipsilateral posterior arch of the atlas. The jugular tubercle is also removed epidurally if the aneurysm is closer to the internal auditory meatus; (3) after dural incision and gentle minimal upward and medial retraction of the tonsil, the aneurysms are well exposed without retraction of the medulla; (4) utilizing these procedures, direct clipping of the aneurysm is easy. This approach is also successfully utilized for proximal VA clip occlusion with wrapping around the dissecting aneurysm.
Postoperative vertebral angiograms revealed that all 8 aneurysms were completely obliterated.
There were two complications: one was transient hoarseness; the other was temporary swallowing disturbance. All 8 patients returned to their preoperative occupations without any neurological deficit.
This approach took a little longer and more effort was needed to reach the stage of dural opening but, once the dura was opened, the aneurysm was usually seen and reached with minimal retraction of the tonsil. For more midline VA-PICA and vertebrobasilar junction aneurysms, this approach has been very satisfactory and is recommended.
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