The current role of microsurgery for posterior circulation aneurysms: A selective approach in the endovascular era

OBJECTIVE: During the past decade, management of posterior circulation aneurysms has shifted away from microsurgery. Currently, microsurgical clipping is considered a primary, competitive alternative to endovascular coiling, or rrore commonly, a secondary alternative when endovascular therapy is unfavorable. We present a large, multidisciplinary team experience with posterior circulation aneulysms in an institution that continues to use microsurgery as a primary treatment modali:y for selected aneurysms. METHODS: During a 9-year period, 217 patients with 228 posterior circulation aneurysms were treated microsurgically; they included 106 basilar bifuilcation, 27 posterior cerebral artery, 23 superior cerebellar artery, eight anteroinferior c'erebellar artery, five basiartery aneurysms. Overall, lar trunk, 47 posteroinferior cerebellar artery, and 12 vertebral ' 81 % of patients presented with hemorrhage, and 33% of thE aneurysms were large or giant in size. RESULTS: Direct clipping was performed in 75% of cases, and the overall rate of angiographic aneurysm obliteration was 98.1 %. Sixteen patients (74%) died after surgery, 25 patients (11.5%) experienced transient neurological deterioration, and 17 patients (7.8%) experienced permanent neurological deterioration,'At late follow-up (mean)w Outcome Scale scores duration, 13.6 mo), 144 patients had good outcomes (Glasgi, of 5 or 4, 66%), and 184 patients (85%) either improved or ,ere unchanged relative to their preoperative baseline. Overall, mean Glasgow Outco6e Scale scores improved from 3.60 to 3.97. CONCLUSION: Despite increasing reliance on endovascular therapy with posterior circulation aneurysms, there is a role for microsurgical therapy Microsurgery remains a competitive, primary therapy for superior cerebellar artery, P'l posterior cerebral artery, distal anteroinferior cerebellar artery, and posteroinferior cerebellar artery aneurysms. Microsurgery has become a secondary therapy for P2 posterior (Prebral artery, basilar trunk, proximal anteroinferior cerebellar artery, vertebrobasilar jun 1-tion, and vertebral artery aneurysms when endovascular therapy is unfavorable. The ptieferred therapy for basilar bifurcation aneurysms remains unclear. Collaborative, M1.11ticlisciplinary teams are strengt hened and results are improved by offering competitivi treatment alternatives for patients to consider and select. Rather than abandoning the, posterior circulation prematurely, aneurysm surgeons should maintain technical prof ciency with these lesions.