Microsurgical Clipping of a Ruptured Basilar-P1 Junction Aneurysm

In current neurosurgical practice, treatment paradigms for posterior circulation aneurysms have shifted away from microsurgical clip ligation toward endovascular therapy. This is largely due to the results of the International Subarachnoid Aneurysm Trial and International Study of Unruptured Intracranial Aneurysms, which, in part, showed that outcomes in patients with ruptured aneurysms were better with coiling and that a location in the posterior circulation was an independent risk factor for poor outcome, respectively.^1,2 Nevertheless, there exist certain anatomic features that highlight the importance of a microsurgical approach. These include small size, wide-neck configuration, and the incorporation of perforators, among other factors. In Video 1, we report a case of a 53-year-old male with a ruptured 2 mm × 2 mm right basilar-P1 junction aneurysm. Endovascular options were deemed less favorable due to the small size of the aneurysm and the hemorrhagic complications associated with dual-antiplatelet therapy in the setting of an acute subarachnoid hemorrhage. A standard right-sided orbitozygomatic approach was performed.³ This video highlights the importance of performing microsurgical clipping for posterior circulation aneurysms in an era with increasing reliance on endovascular treatment.