Bifrontal interhemispheric approach to aneurysms of the anterior communicating artery

The authors review their experience with the bifrontal interhemispheric approach in 603 cases of single anterior communicating artery (ACoA) aneurysms and describe the operative technique. With this approach, the olfactory tracts are dissected, and both A1 segments of the anterior cerebral arteries are identified subfrontally. The interhemispheric fissure is then dissected and A2 segments are followed from the distal portion toward the ACoA complex. Following the administration of a combination of mannitol, vitamin E, and dexamethasone, a temporary clip is placed on at least the dominant A1 segment prior to dissection of the aneurysm itself. Once the aneurysm has been completely freed from the surrounding structures, the neck is ligated and clipped. If the aneurysm ruptures during surgery, temporary clips are placed on both A1 and A2 segments bilaterally and the operation proceeds in a completely dry field. With this method, it is possible to occlude any of the intracranial vessels for up to 40 minutes within 100 minutes of drug administration. To prevent the possibility of rerupture and the development of vasospasm in the period before aneurysm surgery, the authors have adopted a policy of performing ultra-early operations within 48 hours of the onset of symptoms. Among the 257 cases operated on during the 9 years since 1975, one-fifth have been operated on within 48 hours of rupture, and the in-hospital mortality rate has been only 4.3% (11 cases). Follow-up studies have shown that 87% of the 246 surviving patients have returned to useful lives.