Step-by-Step Clipping of Clustered Ipsilateral Anterior Circulation Aneurysms via an Extended Minipterional Approach

We describe the step-by-step microsurgical management of four right-sided incidental clustered ipsilateral anterior circulation aneurysms through a single extended minipterional approach. A 55-year-old woman with right-sided aneurysms involving the A1 segment, anterior choroidal artery, posterior communicating artery, and carotid terminus underwent clipping in a single-stage procedure. Her past medical history included two previously clipped aneurysms of the clinoidal segment of the right internal carotid artery (ICA). The patient was positioned supine with vertex-down tilt and contralateral head rotation to align the surgical corridor along the sphenoid ridge. A 4 × 5 cm craniotomy was performed following extradural sphenoid ridge drilling and anterior clinoidectomy to expose the distal dural ring and secure proximal internal carotid artery control. Sylvian fissure dissection from distal to proximal allowed cerebrospinal fluid drainage and brain relaxation. Aneurysms were clipped sequentially from proximal to distal: first the A1 aneurysm with preservation of perforators, followed by the posterior communicating artery aneurysm, the anterior choroidal artery aneurysm, and finally the carotid terminus aneurysm. Intraoperative fluorescein videoangiography confirmed aneurysm exclusion and patency of parent vessels and perforators. This stepwise proximal-to-distal strategy provided an unobstructed operative field, ensured vascular control, and allowed safe treatment of multiple lesions through a single surgical corridor.