Microsurgical Clipping of a Ruptured Basilar Apex Aneurysm: Contending with a Formidable Clinical Scenario

Basilar apex aneurysms (BAAs) represent 5%-8% of cerebral aneurysms.^1-3 Treating BAAs is long established in neurosurgery.^4-6 The morbid and lethal characteristics of aneurysmal subarachnoid hemorrhage coupled with potential medical complications of neurointensive care contribute to poor prognosis of patients with ruptured BAAs.^7,8 A 58-year-old woman presented to the emergency department with a 1-day course of intense headaches that progressed to loss of consciousness. Noncontrast computed tomography of the head revealed extensive intraventricular hemorrhage (Fisher grade 4). Computed tomography angiography revealed an 8.7 × 6.3 mm wide-neck BAA. Preoperatively, she developed rebleeding and cerebral vasospasm and was transferred to the neurointensive care unit. After initial management and consideration of her clinical course and complex aneurysm features, she underwent a right frontotemporal craniotomy and anterior extradural clinoidectomy to perform aneurysm neck clipping (Video 1). Endovascular treatment was not considered, given that our facility belongs to a low-income public health system with limited availability of endovascular devices. Postoperatively, the patient developed cerebral vasospasm and pneumonia, which led to respiratory failure and death. BAAs are vascular entities that require arduous microsurgical treatment. Despite the increasing trend in managing these patients with endovascular treatment, the role of microsurgery is predominant in clinical settings with limited availability of alternative therapies. This clinical scenario requires neurosurgery trainees to achieve a high-level microsurgical skill set to provide optimal treatment. Nonetheless, the course of BAAs can still be poor even after adequate surgical management. This case exemplifies the burdensome nature of BAAs and the difficult clinical course of patients despite meticulous microsurgical management. Fisher grade 4, which is associated with a 31% risk of vasospasm, was a notable factor contributing to this outcome.⁷ Further, the patient's recovery was complicated by hospital-acquired pneumonia, which has a mortality rate of 9.7%.⁸ Accordingly, amid the emergent discipline of enhanced recovery after surgery, optimized protocols for postoperative management could benefit these patients.^9-11.