A surgery by Dr. Luis Borba
En SurgSchool, the leading app for online surgeries, we present one of the most complex neurosurgical interventions: the microsurgical clipping of an aneurysm at the tip of the basilar artery, made by the renowned Dr. Luis Borba, President-Elect of the World Federation of Neurosurgical Societies (WFNS), current Chairman of the WFNS Education and Training Committee, President of FLANC, and coordinator of multiple neurosurgery services in Curitiba, Brazil.
This clinical case represents a true masterclass in craniobasal approach, precise microsurgical exposure and neurovascular preservation.
Clinical case
Patient: 67-year-old woman
Symptoms: Sporadic headache and hearing loss
Diagnosis: Unruptured, wide-necked saccular aneurysm located at the tip of the basilar artery, visualized by CT angiography and 3D angiography.
Surgical approach: maximum exposure craniobasal approach
1. Preoperative planning
La tortuous anatomy of the basilar artery, the relationship of the aneurysm to the posterior cerebral arteries (PCA) and superior cerebellar arteries (SCA), and the position on the dorsum sellae made it necessary to extended craniobasal approach type COZ (combined orbito-zygomatic).
2. Step-by-step surgical technique
- Orbitozygomatic craniotomy (OZC): Multiple strategic burr holes were made (superior temporal line, zygomatic root, and MacCarty keyhole), followed by osteotomy of the lateral orbit and orbital roof.
- Anterior clinoidectomy: The anterior clinoid process was removed and the optic canal and sphenoid sinus were exposed, significantly increasing the surgical field.
- Middle fossa peeling: The temporal lobe was released and the lateral wall of the cavernous sinus was accessed.
- Dissection of the carotid-oculomotor triangle: The internal carotid artery, the oculomotor nerve, the posterior communicating artery (PCA) were exposed, and the PCA was divided (in the perforator-free zone) to facilitate mobilization of the surgical field.
Clipping aneurysm microsurgery
With the exposed basilar artery and ACP and ACS identified bilaterallyA temporary clip was placed on the proximal basilar artery to facilitate dissection and reduce pressure in the aneurysmal sac. Subsequently:
- They were placed three definitive clips, adjusting its position to ensure total exclusion of the aneurysm and preserving the perforating arteries and main vessels.
- It has been made dome puncture to confirm the exclusion of the flow and a final safety clip was added.
Intraoperative and postoperative results
- Intraoperative Doppler: Confirmed the patent of the basilar artery, both ACP and both ACS.
- Postoperative angiography: He showed the complete occlusion of the aneurysm and conserved flow in the posterior system.
- Complications: Only one transient paralysis of the third cranial nerve, without permanent neurological sequelae.
Conclusion
El microsurgical clipping of basilar aneurysms remains one of the most challenging procedures in neurosurgery. This case, uploaded to the online surgery app SurgSchool, demonstrates the importance of precise anatomical approach, the three-dimensional planning and advanced microsurgical technique.
