Dural opening: k-shaped dural opening with a linear incision across the band at the foramen

magnum ( some patient have a sinus known as the arcuate sinus here that may require vas
ular clips).
Approach : first, gain proximal control of the VA where it first becomes intradural ( in case of
aneurysmal rupture). Retract cerebellum superiorly ( caution: anneurysma dome may be
adherent). Follow VA up from point where in enteres dura; PICA origin then encountered
usually just at neck of aneurysm (PICA origin may be confused for continuation of VA ).
Dissection must spare branches of pharyngeal filaments of spinal accessory nerve and lower
filaments of vagus. May placed between the fibers of IX & X above and XI below. It is better
to to leave a small residual aneurysma than to risk compromising PICA
Postoperative care: when neuropraxia of the lower cranial nerves is likely ( in cases of
difficult dissection or traction aplied during clipping) the patien is kept intubated overnight.
Patients who do not tolerate extubation at this point are immediately reintubated and elective
tracheostomy is scheduled. Tracheostomy is maintained until the neuropraxia resolves
Saccular aneurysms located where the two vertebral arteries join often form at the location of
a basilar artery fenestration ( basilar fenestration basilar)
Ct-angiography may be helpful as an adjunct because it can opacify both vertebral arteries
simultaneously ( not generally feasible with catheter angiogram)
1. Suboccipital approach : for most; performed in lateral oblique position
2. Subtemporal-transtentorial approach if the vertebrobasiler junction is high;
performed in supine position
May occasionally be seen on CT or MRI as round mass in region of suprasellar cistern. With
SAH, Tend to see blood in interpeduncular cistern with some reflux into 4th (and to a lesser
extent, third and lateral) ventricle. Occasionally may mimic pretruncal nonaneurysmal SAH
Dome usually points superiorly. Should evaluate flow through posterior communicating
arteries ( may require Allock test) in case trapping is required. Need to assess the heigh of the
basiler bifurcation i n relation to the dorsum sella (see approaches below)

Management recommendations basedon aneurysma size

Numerous recomendation have been made for critical size above which an unruptured
aneuriysma should be considered for surgery, and haveincluded 3 mm, 5mm , 7mm, and 9
mm. And again, the patients expected longevity must be taken into account. One proposal is
to promptly treat unruptured aneurysma > 10mm, to repair those measuring 7-9 mm in young
and middle-aged patient, and to follow smaller aneurisma with serial angiograpi.
Summary of the american heart assiciation stroke council recomendation
Table 30-14 summarizes factors favoring treatment made based on a review of the literature
(only level IV and V evidence was found, and therefore only grade C recomendations can be
made ( i.e. an array of potential actions. Any of which could be considered appropriate).
Patient for whom expectant management is elected should have periodic CT, MRA or
selective contrast angiograpi seeking changes in aneurismasize or configuration.
Symptomatic large or giant aneurysma carry increased risk of treatment.
In all treatment dicisions, coexisting medical conditions must be taken into account.
Recommended follow-up for UIAs

Annual follow up TOF MRAs are recomended for most incidental aneurysma yhat are not
treated. Intervention is indicated for any documented growth.
Background : The morbidity from catheter arteriograms is probably too nhigh to recomend
them for this purpose. CTA is more accurate than MRA, but involves iodinecontrast and
radiation. A TOF-MRA (not gadolinium-MRA) has no known risk and does not involve
radiation.
Unfortunately, most aneurisma rupture without demostrable enlargement on follow up.
Aneurysma do not grow at a constant rate, and it may take several years to appreciate a
milimeter of increased size on MRA. Over a 47 month median follow up, only 10% of
aneurysma enlarged on follow up MRA. Larger aneurysma (>8 mm original diameter) more
frequently showedgrowth. An aneurysma showing any growth should be treated ( it is not
really known if enlargement is associated with increased risk of rupture, but there are
probably few situations like this where the physician would be willing to wait and see.
Unruptured cavernous carotid artery aneurisma
Most cavernous carotid artery aneurysma (CCAAs) develop on the horizontal segment of the
artery
Presentation :
1. CCAAs may be discovered incidentally
a. On arteriograpi for other reason
b. On MRI

c. Occasionally on CT
2. When symptomatic :
a. Usually present with :
1. Headache
2. Cavernous sinus syndrome ( see page 1204): promarily produces diplopia
( due to ophthalmoplegia). Classically the third nerve palsy from enlarging
CCAA WILL not Produce a Dilated pupil because the sympathics which
dilate the pupil are alsoparalyzed
3. Those that expand through the carotid ring into the subarachnoid space may
cause monocular blindness
b. Rarely, pain (retro-orbital or pain mimicking trigeminal neuralgia or carotid
cavernous fistula (CCF) are the sole manifestation
c. When CCAAs rupture, they usually produce a CCF
d. Life threatening complication are rare, but may be more common with giant
intracavernous aneurysma. Manifestation include
1. SAH
2. Arterial epitaxis from rupture into sphenoid sinus (Usually with traumatic
aneurisma, see page 1081)
3. emboli