Multimodality Techniques in Microsurgical Clipping as the Gold Standard Treatment in the Management of Basilar Tip Aneurysm: A Case Series

Introduction: Basilar aneurysms represent 5%-7% of all intracranial aneurysms. The main goal of open surgery is to achieve complete obliteration of the aneurysmal sac using minimal invasive technique while emphasizing on avoidance of complication.

Materials and Methods: We performed a retrospective cohort study of nine cases of unruptured basilar tip aneurysm referred to the Fujita Health University Banbuntane-Hotokukai Hospital, Japan. The objective of the study was to analyze the surgical outcomes of unruptured basilar tip aneurysm.

Results: Nine patients with unruptured basilar tip aneurysm were referred to our hospital between 2015 and 2017. The median size of the aneurysm and age were 4.00 mm (interquartile range [IQR] = 3.25-6.75 mm) and 58 years (IQR = 54-70 years), respectively. Five patients (55.6%) were presented with multiple intracranial aneurysms. Surgical adjuncts such as intraoperative neuromonitoring, intraoperative indocyanine green (ICG) angiography with dual-image videoangiography (DIVA), and neuroendoscope were used. Two patients developed transient postoperative oculomotor nerve palsy which resolved spontaneously. The median duration of surgery and days of hospitalization were 292 min (IQR = 237.5-350.5 min) and 12 days (IQR = 12-25 days), respectively. There was no mortality recorded in this case series.

Conclusion: Microsurgical clipping of basilar tip aneurysm is safe in unruptured basilar tip aneurysm with a low risk of postoperative mortality or morbidity. All complications reported in this case series were transient with no long-term sequalae. The improved safety profile of microsurgical technique is due to the availability of intraoperative neuromonitoring, neuroendoscope, ICG, and DIVA. The application of multimodality technique in neurovascular surgery has also helped to achieve complication avoidance. The obliteration of the aneurysmal sac helps to restore the laminar blood flow in the bifurcation and distal blood vessels and improves the brain perfusion.