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Review
. 2018 Feb 21:9:44.
doi: 10.4103/sni.sni_311_17. eCollection 2018.

Should we still consider clips for basilar apex aneurysms? A critical appraisal of the literature

Mardjono Tjahjadi  1 , Joseph Serrone  2 , Juha Hernesniemi  3
Affiliations
Review

Should we still consider clips for basilar apex aneurysms? A critical appraisal of the literature

Mardjono Tjahjadi et al. Surg Neurol Int. .

Abstract

Background: Basilar apex aneurysms constitute 5-8% of all intracranial aneurysms, and their treatment remains challenging for both microsurgical and endovascular approaches. The perceived drawback of the microsurgical approach is its invasiveness leading to increased surgical morbidity. However, many high-volume centers have shown excellent clinical results with better occlusion rates compared to endovascular treatment. With endovascular therapy taking a larger role in the management of cerebral aneurysms, the future role of microsurgery for basilar apex aneurysm treatment is unclear.

Methods: We performed a literature search to review the microsurgical and endovascular outcomes for basilar apex aneurysms.

Results: Many studies have examined the efficacy of microsurgical and endovascular treatment for intracranial aneurysms, including large randomized trials such as ISAT and BRAT, prospective observational series such as ISUIA, and many single-center retrospective reviews. The recruitment number for posterior circulation aneurysms, specifically for basilar apex aneurysms, was limited in most prospective trials, thus failing to offer clear guidance on basilar apex aneurysm treatment. Recent single-center series report good clinical outcomes between 57-92% for surgical series and 73-96% in endovascular series. The durability of aneurysm occlusion remains superior in surgical cases. The techniques and devices in endovascular treatment have improved treatment aneurysm occlusion rates but more follow-up is needed to confirm long-term durability.

Conclusions: Both microsurgical and endovascular approaches should be complementing each other to treat basilar apex aneurysms. Although endovascular therapy has taken a larger role in the treatment of basilar apex aneurysms, many indications still exist for the use of microsurgery. Advancements in microsurgical techniques and good case selection will allow for acceptably low morbidity after surgical treatment while maintaining its superior durability.

Keywords: Basilar apex aneurysm; endovascular; microsurgical.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
(a and b) Anterior and lateral view of angiography showed an unruptured medium sized basilar tip aneurysm. (c and d) A left-sided presigmoid approach was selected to clip the aneurysm. The exposure of the aneurysm and its surrounding structures were excellent and all vital neurovascular structures were preserved. (e and f) Anterior and lateral view of angiography showed total occlusion of the aneurysm while preserving all parent and branches vessels. An = aneurysm; BA = basilar artery; III = third nerve; P2 = second segment of posterior cerebral artery; Pcomm = posterior communicating artery
Figure 2
Figure 2
(a) A pre-operative angiography of a small basilar tip aneurysm projected superolaterally. (b) The aneurysm was occluded with stent-assisted coiling technique
See this image and copyright information in PMC

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