The endonasal approach for treatment of cerebral aneurysms: A critical review of the literature

Abstract

The last two decades of neurosurgery have seen flourishing use of the endonasal approach for the treatment of skull base tumors. Safe and effective resections of neoplasms requiring intracranial arterial dissection have been performed using this technique. Recently, there have been a growing number of case reports describing the use of the endonasal approach to surgically clip cerebral aneurysms. We review the use of these approaches in intracranial aneurysm clipping and analyze its advantages, limitations, and consider future directions. Three major electronic databases were queried using relevant search terms. Pertinent case studies of unruptured and ruptured aneurysms were considered. Data from included studies were analyzed. 8 case studies describing 9 aneurysms (4 ruptured and 5 unruptured) treated by the endonasal approach met inclusion criteria. All studies note the ability to gain proximal and distal control and successful aneurysm obliteration was obtained for 8 of 9 aneurysms. 1 intraoperative rupture occurred and was controlled, and delayed complications of cerebrospinal fluid leak, vasospasm, and hydrocephalus occurred in 1, 1, and 2 patients, respectively. Described limitations of this technique include aneurysm orientation and location, the need for lower profile technology, and challenges with handling intraoperative rupture. The endonasal approach for clipping of intracranial aneurysms can be an effective approach in only very select cases as demonstrated clinically and through cadaveric exploration. Further investigation with lower profile clip technology and additional studies need to be performed. Options of alternative therapy, limitations of this approach, and team experience must first be considered.

Keywords: Cerebral aneurysm; Clipping; Endonasal; Endoscopic.

Figure 1

Illustration depicting the location, proportional size, and orientation of intracranial aneurysms treated with an endonasal approach (modified from Wikipedia).

Figure 2

Drawing demonstrating view of intracranial neurovascular structures following endonasal transsellar/transtubercular/transplanar approach with bilateral medial clinoidectomy from a 0° endoscope.

Figure 3

Drawing demonstrating closer view of intracranial neurovascular structures following endonasal transplanar approach from a 30° angled endoscope.

Figure 4

Drawing demonstrating view of intracranial neurovascular structures following endonasal transsellar and upper transclival approach with posterior clinoidectomy and pituitary transposition from a 0° endoscope.

Figure 5

Drawing demonstrating view of intracranial neurovascular structures following endonasal mid- and lower transclival approaches from a 0° endoscope. A microdissector is used to show the posterolateral position of the proximal PICA.