Transcavernous Transclinoidal Half-and-Half Approach for Clipping of Twice-Recurrent Stent-Coiled Giant Basilar Tip Aneurysm: 3-Dimensional Surgical Video.

The authors present a 3-dimensional surgical video of a half-and-half, transcavernous approach for microsurgical clipping of a giant basilar tip aneurysm that recurred twice after endovascular treatment. The case refers to a 60-year-old man who presented with subarachnoid hemorrhage, was treated with coiling, and had a good clinical and radiographic outcome. At 3 months, he was found to have recurrent filling at the neck of the aneurysm and was treated again endovascularly with stent coiling. Three months after his second treatment, again he was found to have filling of the base of the aneurysm and was referred for microsurgical clipping. The video analyzes the surgical steps of the half-and-half transcavernous approach for the microsurgical clipping of the basilar tip aneurysm. After positioning, an orbitozygomatic craniotomy is performed, followed by an extradural anterior clinoidectomy and dissection of the temporal dura from the lateral wall of the cavernous sinus. The dura is then opened, and the sylvian fissure is split widely, followed by extensive arachnoidal dissection to completely free the temporal from the frontal lobes. The transcavernous approach is then performed, followed by a posterior clinoidectomy and division of the posterior communicating artery. After multiple failed clipping attempts, the aneurysm was trapped and opened to remove some of the coils from the neck. This accommodated permanent clipping with preservation of all major vessels and complete obliteration of the aneurysm neck.