Journal of Craniofacial Surgery Pure Endoscopic Endonasal Clipping of an Incidental Anterior Communicating Artery Aneurysm: Technical Note

AbstractAnterior communicating artery (AcoA) aneurysm is the most common form of intracranial aneurysm. It occurs rarely together with other intracranial lesion. Today, microsurgical techniques and endovascular methods are used in the treatment of these aneurysms. Endoscopic endonasal approach is a useful technique for midline lesions of the skull base and is underpinned with extensive experience. In this article, we present a 72-yearsold female patient who underwent endoscopic endonasal transplanum-transtubercular surgery for tuberculum sellae meningioma followed by clipping of the incidental AcoA aneurysm. After complete removal of a tuberculum sellae meningioma via an endoscopic endonasal approach, an anterior and superior projected saccular AcoA aneurysm in the gyrus rectus area was totally clipped successfully via pure endoscopic endonasal transplanum-transtubercular approach, without any damage to parent arteries. The patient was discharged from the hospital within a short period of time without any postoperative complication. Endoscopic endonasal approach is a new paradigm in the treatment of aneurysm. Although this technique can not be routinely used due to lack of experience, it is an effective and safe method in selected and anatomically appropriate cases. We believe that increased knowledge and experience will create successful results in this approach, and it can offer an alternative method for selected aneurysm cases.

Key words:Aneurysm, Anterior communicating artery, endonasal, endoscopic clipping

Introduction:Cerebral aneurysm and its management remains a frequent and challenging problem in neurosurgery. It is also more important to isolate an aneurysm from the normal circulation without causing any further harm to the patient. Anterior communicating artery (ACoA) aneurysm is the most common form of intracranial aneurysm, accounting for 30-37% of total cerebral aneurysm cases (1). These aneurysms are treated by microsurgical clipping or endovascular technique over the years. Surgical approaches currently represent the gold standard for treatment of intracranial aneurysms, and specifically the pterional transsylvian, pterional subfrontal, and interhemispheric approaches are mostly preferred (1). However, sylvian fissure dissection, frontal lobe retraction, and partial gyrus rectus resection are performed to improve the exposure of the ACoA complex, and these processes can also cause damage to the healthy brain tissue (1). As a result, physiological risk factors and the risk of neuropsychological morbidity is increased. In recent years, less invasive techniques, such as keyhole approaches and supraorbital craniotomy have been used to reduce morbidity, but their usefulness is limited to selected cases (1). The brain tumors associated with cerebral aneurysms are not rare in neurosurgical practice, with an incidence of 0.7- 5.4 % (2, 3, 4, 5). The most common brain tumors associated with intracranial aneurysms are meningioma, pituitary adenoma, glioma, lipoma and metastatic tumors (4, 6, 7, 8, 9). While the most common brain tumor associated with aneurysm is meningioma, the most common aneurysms associated with brain tumors are internal carotid artery (ICA) and AcoA aneurysms (10, 11). In addition, the aneurysms associated with tumors are mostly unruptured aneurysms (10). The endoscopic endonasal approach is now widely used for pituitary adenomas. In addition, it is increasingly being performed for lesions around ventral anterior skull base and suprasellar lesions. Moreover, the technological development of endoscopy and instruments has facilitated the manipulation in these areas. In the light of these developments, endoscopic endonasal approach to AcoA complex has achieved considerable interest, because it is a minimally invasive method, and provides a panoramic view and direct access with no need for cerebral retraction (12). In this article, we present a 72-years-old female patient who underwent endoscopic endonasal resection of a tuberculum sellae meningioma through a transplanum transtubercular approach followed by pure endoscopic endoonasal clipping of the incidental AcoA aneurysm. Our aim is to show that appropriate vascular lesions can be treated with this minimally invasive technique, but undoubtedly this technique will become more precise as it evolves and as further experience is gained..