Microsurgical Treatment of Distal Anterior Cerebral Artery Aneurysms: 3-Dimensional Operative Video

Selecting appropriate patient position for surgery must take into consideration a variety of factors. For an interhemispheric approach to distal anterior cerebral artery (DACA) aneurysms, the patient may be positioned with the head either horizontal or vertical with respect to the floor. We preferentially place the patient in the supine position with the shoulder elevated and the head turned parallel to the floor with the side of the approach down and the vertex tilted 45° up. In this way, gravity is utilized to allow the right frontal lobe to fall away from the falx, eliminating the need for retraction. To demonstrate the importance of individualizing the choice of position to each patient, we present here 2 illustrative cases of DACA aneurysms in which different positioning was selected. One patient presented with a 7-mm bilobed pericallosal artery aneurysm; the aneurysm was approached with the head horizontal with respect to the floor. The second patient had a 3-mm DACA aneurysm and a right frontal proliferative angiopathy and developmental venous anomaly with evidence of prior hemorrhage. Due to the vascular anomaly, we positioned the head in a vertical position for surgery to clip the aneurysm, which was thought to be the source of hemorrhage. The videos illustrate the approach to DACA aneurysms, which typically exposes the aneurysm before complete exposure of the proximal parent artery is obtained. In one case, the use of both frameless guidance and intraoperative angiography was useful in identifying a small previously ruptured aneurysm. All appropriate patient consents were obtained for this submission. Video and Figures (0:57-1:16 and 6:30-6:37), © 2017 Department of Neurosurgery, Emory University. Used with permission.