Microsurgical clipping of multiple aneurysms through the unilateral pterional approach via the extended lateral corridor (PAVEL): a case report

The application of pterional approach via the extended lateral corridor (PAVEL) for aneurysms of the distal basilar artery has been associated with significant successes. However, this approach has been rarely used to manage multiple aneurysms in patients who are not candidates for endovascular intervention.

A 58-year-old male patient was referred to our neurosurgical unit with severe headache, nausea and vomiting, and neck pain. The patient had a history of hypertension but no past surgical history. A computerized tomography scan showed subarachnoid hemorrhage in the basal cisterns. Also, three-dimensional cerebral vascular imaging revealed three aneurysms involving the left middle cerebral artery, the basilar artery apex, and the left superior cerebellar artery. Due to his comorbidities and the severity of his symptoms, an endovascular intervention was not possible. The patient underwent the PAVEL approach to clip these three aneurysms. Following surgery, the patient had temporary right-sided hemiparesis and left-side ptosis, which improved 3 months after surgery.

In this article, we present a narrated video of the intraoperative management of the three aneurysms and discussed the benefit and likely complications of this procedure.

The PAVEL approach provides a single approach for multiple anterior and posterior circulation aneurysms instead of multiple procedures, thus minimizing patient postsurgical morbidity and mortality.