Surgical Management of Bilateral Middle Cerebral Artery Aneurysms via a Unilateral Supraorbital Key-Hole Craniotomy

Introduction: Surgical management of multiple intracranial aneurysms may be difficult if located bilaterally. In the case of bilateral middle cerebral artery (MCA) aneurysms, surgical treatment through a unilateral approach is generally not recommended. In this study we describe the surgical technique and important factors that enable treatment of bilateral MCA aneurysms via a unilateral key-hole approach. Patients and Methods: 15 patients (12 females, 3 males) with bilateral aneurysms of the MCA were surgically treated via a supraorbital keyhole approach. Age ranged from 37 to 60 years (mean: 47). 7 of the 15 patients presented with an acute subarachnoid hemorrhage (SAH). Cerebral angiography was performed in all patients pre- and postoperatively. Patients suffering from SAH were treated within the first 72 h. All 15 patients were planned to be operated via a unilateral supraorbital keyhole craniotomy using an eye-brow incision. Results: In 10 of the 15 patients MCA aneurysms of both sides could be occluded completely through the unilateral approach. In 5 patients bilateral craniotomies had to be performed, in 1 of these patients during the same procedure. Factors necessitating a second craniotomy were brain swelling (1 patient with SAH), insufficient instruments (2 patients), and complex configuration of the contralateral aneurysm (2 patients). Permanent morbidity was anosmia in 1 patient and hyposmia and a mild visual held deficit in 1 further patient. Conclusion: Bilateral aneurysms of the MCA may be treated sufficiently through a unilateral supraorbital key-hole approach in selected patients. This is also possible in patients presenting with SAH. Factors necessitating bilateral craniotomies were brain swelling and complex configuration of the contralateral aneurysm.