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This case demonstrates a half and half approach for multiple aneurysms. This is a 53-year-old woman with unilateral renal agenesis, incidentally found to have a right superior cerebellar artery aneurysm in a workup for dizziness. She had a formal angiogram which demonstrated additional bilateral MCA aneurysms, the right being greater than the left.

Here you see on her preoperative DSA the left MCA aneurysm which is very small and the larger 5 millimeter right MCA aneurysm. She also had an 18 millimeter superior cerebellar artery aneurysm that was pointing directly posterior. Given the projection of this aneurysm and its size we recommended treatment and using a subtemporal approach to treat the basilar aneurysm and then a traditional frontotemporal transylvian approach for the middle cerebral. This operation is quite unusual in that it uses a larger approach to perform two separate trajectories in and around the temporal lobe, the first being a standard transylvian approach to a middle cerebral aneurysm, the second being a subtemporal approach to optimize the trajectory to the superior cerebellar artery aneurysms. This may increase the possibility of temporal lobe injury or dysfunction, given the fact that we are dissecting from two different directions through a larger craniotomy.

The patient is placed supine on the operating table with her head turned 60 degrees to the left to be able to clip both aneurysms. Here's the scalp flap that is used.

After opening the scalp, the temporalis muscle is incised and a myocutaneous flap is retracted anteriorly.

We perform a standard frontotemporal craniotomy and then drill the middle fossa floor completely flat. We then open up the dura in a C-shaped fashion with an extension posteriorly. This allows the subtemporal approach. We then start our subtemporal approach. We identify the tentorial edge and the third nerve. The ambient cistern is evident and we open up the membrane of Lilliequist. You can see the anatomy here. We then expose the upper basilar trunk, which is identified here with the perforators emanating from this region. We free up the basilar artery from its arachnoid investment and identify the neck of the posterior projecting aneurysm. The aneurysm is embedded in the pons. We open up the tentorial edge, just behind the entrance of the fourth nerve, cauterize this, and then place a 4-0 stitch to reflect the flap out of the way. This affords more room in working on the subtemporal approach.

We then identify the neck of the aneurysm on both sides and place a single Sugita clip across the neck. Taking care not to clip perforators on the distal side of the aneurysm. We then release the tentorial stitch and obtain hemostasis. We'll then turn our attention to clip the middle cerebral artery aneurysm. We open up the Sylvian fissure from an inside-out fashion. Identify the distal MCA branches. And here we're identifying the M1 aneurysm. We open up the fissure enough to be able to identify the more proximal M1 and free the artery of any crossing branches to identify clearly the neck of the aneurysm. A straight Sugita clip is placed across the neck of the aneurysm. The aneurysm is completely secured and we'll document the patency of the artery with Doppler. And open up the dome of the aneurysm to ensure that it does not fill. All perforators are left intact. Hemostasis is secured. And a small bleb at the bifurcation is covered with muslin gauze. Durafoam covering is placed over the blood vessels. The dura is closed using Neurolon suture, and the bone flap is replaced using titanium mini-plate fixation. A Medpor cranioplasty is used to cover the temporal defect. Muscles are closed in separate layers. And the scalp is closed. Her postoperative imaging demonstrates stable appearance of the clips and no evidence of infarction as demonstrated here on the MRI. She had a complete clipping of the right SCA and right MCA aneurysm and she remained neurologically stable after procedure and in her follow up one year following surgery. Thank you very much.