Surgical approaches for vertebro-basilar trunk aneurysms located in the midline

Fourteen cases of midline vertebro-basilar trunk aneurysms were operated on by four routes of surgical approach: middle fossa anterior transpetrosal approach (ATP), presigmoid transpetrosal approach (PTP), conventional lateral suboccipital approach (LSO) or suboccipital transcondylar approach (STC). There was no mortality, but the morbidity was different depending on the surgical approach. In basilar trunk aneurysms located higher than the internal auditory canal, excellent results were obtainable by ATP, especially in the case of posteriorly projecting aneurysms. For midline vertebral aneurysms located lower than the internal auditory canal, STC resulted in less surgical complications than LSO. Extradural resection of the jugular tubercle was necessary for aneurysms located on the distal vertebral artery at or close to the vertebro-basilar junction. For vertebro-basilar junction aneurysms located at the level of the internal auditory canal, hearing was preserved by STC, but not by ATP or PTP. However, choice of the surgical approach may depend on the direction of the aneurysm and the technical accessibility of the skull base. All these skull base approaches reduced surgical complications of retraction damage to the cranial nerves and the brain stem. This holds true for all aneurysms arising from the midline vertebro-basilar trunk.