Vascular Neurosurgery
17
Anterior Circulation Aneurysms
ALEXANDER M. MASON, DANIEL LOUIS BARROW
CLINICAL PEARLS
requirements.
Introduction
Intracranial saccular or berry aneurysms are common, occur-
ring in approximately 1% to 3% of the population.1 Based on
a review of 1450 unruptured intracranial aneurysms (UIAs) in
83 study populations, the overall prevalence is estimated to be
3.2%, with a mean age of 50 years and a higher prevalence in
women, in patients with autosomal dominant polycystic
kidney disease, and in those with a family history of a ruptured
cerebral aneurysm.2 Other associated disorders with a higher
incidence of intracranial aneurysms include multiple endo-
crine neoplasia type I,3 hereditary hemorrhagic telangiectasia,4
Ehlers-Danlos syndrome type IV,5 neurofibromatosis type I,6
and Marfan syndrome.7
Anterior circulation aneurysms comprise roughly 85% of
intracranial aneurysms and are classified based on their ana-
tomic location,8 most commonly at the anterior communicat-
ing artery, middle cerebral artery bifurcation, ophthalmic
artery, and the branching points of the internal carotid artery
(ICA), including the ophthalmic, superior hypophyseal, pos-
terior communicating, and anterior choroidal arteries and the
ICA bifurcation (Table 17.1). The cavernous segment of the
ICA is also a common location for aneurysm formation. These
aneurysms are generally extradural and have a different natural
history and set of therapeutic options.
Imaging
Intracranial aneurysms are increasingly found on cross-sectional
imaging studies, including computed tomography (CT) and
264
instances.
magnetic resonance imaging (MRI), which are performed for
other clinical reasons; however, as many as 50% of aneurysms
are found after an initial subarachnoid hemorrhage.9 Although
screening studies of CT and MRI are useful, computed tomog-
raphy angiography (CTA) and magnetic resonance angiogra-
phy (MRA) can typically define the location and morphology
of aneurysms with a greater degree of certainty. Aneurysms that
are >3 to 4 mm are commonly identified on these noninvasive
imaging studies, depending on the equipment, software, and
clinical experience.10,11 For routine screening or following
intracranial aneurysms, noninvasive imaging studies are pre-
ferred when possible, and although these can also be used for
treatment planning in some situations, catheter angiography
remains the gold standard for defining aneurysms and their
morphology. The advent of three-dimensional (3D) rotational
angiography has significantly improved the ability to resolve
and model the angioarchitecture, associated perforators, and
parent vessels.
Anatomy
A comprehensive understanding of the vascular anatomy along
with a robust knowledge of aneurysm location and nuances are
of supreme importance. There are general tenets that apply
to all intracranial aneurysms, as well as location-specific
nuances should be considered. Anatomy, both general vascular
anatomy and that of aneurysms and other cerebral vascular
disease, should be a fundamental foundation that can help
with the study and mastery of cerebral aneurysms and their
treatment.

TABLE
Anterior circulation aneurysms
17.1
Aneurysm Location Frequencya
Cavernous part of carotid artery 8.3%
Internal carotid artery 29.9%
Anterior communicating or anterior cerebral 12.3%
artery
Middle cerebral artery 29.0%
Posterior communicating artery 8.5%
Vertebrobasilar system (other than basilar tip) 4.9%
Tip of basilar artery 7.0%
a
Reported frequencies result from the International Study of Unruptured
Intracranial Aneurysms (ISUIA) trial of 4060 patients.
Internal Carotid Artery
The origin of the ICA in the neck is usually lateral to the
external carotid artery at the bifurcation and courses cephalad
toward the skull base. Carotid-basilar anastomoses are impor-
tant to recognize, both diagnostically and in treatment plan-
ning. Most common is the primitive trigeminal artery (PTA),
which connects the cavernous ICA with the embryonic dorsal
longitudinal neural arteries.12 Beginning at the bifurcation, the
carotid is divided into seven numbered and named segments,
each identifying its anatomic location: C1, cervical segment;
C2, petrous segment (vertical and horizontal segments); C3,
lacerum segment; C4, cavernous segment; C5, clinoidal
segment; C6, ophthalmic segment; and C7, the communicat-
ing segment13 (Fig. 17.1).
Anatomically, the cervical segment (C1) begins at the carotid
bifurcation (at approximately the fourth cervical vertebra) and
courses to the skull base. The petrous segment (C2) begins at
the entrance of the carotid into the carotid canal at the base of
the skull, where it courses vertically then horizontally (antero-
medially). The ICA then exits the carotid canal, to begin the
lacernal segment (C3), where the carotid continues over the
foramen lacerum; this short segments ends at the petrolingual
ligament.14 The cavernous segment (C4) passes through the
cavernous sinus, from the lateral dural ring proximally, and
exits at the distal dural ring. The clinoidal segment (C5) rep-
resents a very short segment that extends from the distal to
the proximal dural rings, beneath the anterior clinoid process.
The ophthalmic segment (C6) starts at the proximal dural
ring, whereby the carotid enters the subarachnoid space, and
ends at the posterior communicating artery. The absence of
a reliable angiographic landmark at the clinoidal-ophthalmic
(C5–C6) junction makes this difficult to identify on angiog-
raphy; adjunctive studies such as MRI or CTA can be helpful.
The C6 segment gives rise to the ophthalmic artery, and this
has traditionally been used to help identify the beginning
of this segment. In practice, cerebral aneurysms that are at,
or distal to, the ophthalmic artery are considered to be at
CHAPTER 17 Anterior Circulation Aneurysms 265
A1 M1 CN II
Distal ring
C7 Tentorium
C6
C5
ACP C4
Proximal ring
C3
Petrolingual
ligament C2
Carotid
canal
C1
ECA
ICA
Common
carotid artery
Figure 17.1 The segments of the carotid artery. The segments of the
internal carotid artery are as follows: cervical segment, or C1; petrous
segment, or C2; lacerum segment, or C3 (together C2 and C3 compose
the “petrous portion”); cavernous segment, or C4, (functionally identical
to the commonly used “cavernous portion”); clinoidal segment, or C5;
ophthalmic or supraclinoid segment, or C6; and communicating or termi-
nal segment, or C7 (C6 and C7 together constitute the commonly used
“supraclinoid segment”).
least partially intradural and within the subarachnoid space.
The carotid siphon, also known as the anterior loop (in the
Dolenc classification), contains the distal cavernous segment,
the entire clinoidal segment, and the proximal ophthalmic
segment.15 The communicating segment (C7) begins at the
posterior communicating artery and concludes at the ICA
bifurcation, where the ICA divides into the anterior and middle
cerebral arteries.
Branches that are diagnostically or clinically relevant are
important to understand and identify. The cervical segment
(C1) has no regular branches. The petrous segment (C2) has the
caroticotympanic artery and, inconsistently, the vidian artery.
The cavernous segment (C4) has several branches including
the meningohypophyseal artery, which divides into the inferior
hypophyseal artery, the dorsal meningeal artery and the tento-
rial artery of Bernasconi and Cassinari, the inferolateral trunk,
and the capsular arteries of McConnell. Although these rep-
resent important functional vascular components and can be
involved in dural arteriovenous fistulas as well as blood supply
266 PART 3 Vascular Neurosurgery
to meningiomas, they do not regularly play a role in cerebral
aneurysms. Additionally, cavernous segment aneurysms are not
infrequently identified, but, with exceptions that are typically
limited to giant aneurysms, they are extradural. Unfortunately,
large or strategically placed aneurysms can occasionally become
symptomatic from focal pressure on structures within the
cavernous sinus and may require treatment—typically using
endovascular techniques. Although the ophthalmic segment
(C6) gives rise to the ophthalmic artery in 90% of anatomic
dissections,16 in a small percentage of cases it may originate
in the clinoidal segment (C5) or, rarely, more proximally. A
branch of the ophthalmic artery, the lacrimal artery, gives rise
to the recurrent meningeal artery, passes retrograde through
the superior orbital fissure, and anastomoses with branches
of the middle meningeal artery, which can have important
clinical implications.12 Additionally, a number of extraorbital
ophthalmic artery branches have extensive anastomoses with
ethmoidal and facial branches of the external carotid artery and
can be an important source of blood flow to the distal ICA in
the event of a more proximal occlusion. The second important
named artery of the C6 segment is the superior hypophyseal
artery (SHA); this and the ophthalmic artery can be sites
of aneurysm formation. The communicating segment (C7)
has two branches. First, the posterior communicating artery
branches inferolaterally and immediately wraps beneath, trav-
eling posteriorly to merge with the posterior cerebral artery
(PCA) at the P1–P2 junction. A fetal PCA is a normal variant
of the circle of Willis, where the ipsilateral P1 is atretic or
hypoplastic, and the dominant supply to the distal posterior
cerebral artery is from the posterior communicating artery. As
such, when a fetal PCA is identified, it must be preserved. The
second branch is the anterior choroidal artery, which may be
duplicative and is also a common site of aneurysm formation.
The ICA terminus is the bifurcation of the A1 and M1, and
it has distal branches that perforate the anterior perforating
substance and supply the internal capsule.
The anterior cerebral artery (ACA) arises from the ICA
above the optic nerve as A1 and travels ventromedially to the
anterior communicating artery complex (ACOMM); during
this course it has several (as many as 12) medial lenticulostriate
arteries that branch both posteriorly, supplying the anterobasal
brain, and inferiorly, supplying the optic chiasm and nerves
(Fig. 17.2). Additional perforators can come posteriorly from
the ACOMM to supply the hypothalamus and the columns
of the fornix as well as other structures, and as such, oblitera-
tion of the communicating artery in aneurysm management
should be avoided whenever possible. The recurrent artery (of
Heubner) is the largest and typically the longest ACA perfora-
tor, which branches from the proximal A2 or distal A1. The
ACOMM can be hypoplastic or atretic in some patients, but
the patency of the lenticulostriate arteries can be assumed to
be present.
After branching to the contralateral A1 segment through
the communicating artery, within the interhemispheric fissure,
the A2 segment transverses the interhemispheric fissure,
paired with its contralateral counterpart. Variability of the
communicating segment is the rule, and a number of anatomic
variants have been commonly described, with duplication,
triplication, fenestrations, loops, and other anomalies often
found. The A2 segment extends from the ACOMM of the
corpus callosum. The orbitofrontal and frontopolar arteries
branch consistently from this segment. At the rostrum of the
corpus callosum, the A2 branches into the pericallosal artery,
now A3, and its more superficial branch, the callosomarginal
artery. This represents a common site of aneurysm formation
in this segment, and anatomic variability typically is seen with
the location of the branch site. The callosomarginal artery,
which travels in the cingulate sulcus, branches into the medial
frontal artery and the paracentral artery. A common anatomic
variant is the absence of the callosomarginal artery, with ter-
minal branches arising directly from the pericallosal artery.
Distal A3 branches include prefrontal (often from the calloso-
marginal artery), paracentral, and parietal branches.
The second main trunk from the ICA bifurcation is the
middle cerebral artery (MCA). The MCA begins at this major
branch point and travels within the Sylvian fissure (lateral
fissure) to yield multiple branches (Fig. 17.3). The branching
and origin of the MCA are relatively consistent anatomically,
although variants exist including duplication or hypoplasia.
The M1 segment travels deep within the Sylvian fissure, and its
orientation and length are variable. The medial lenticulostriate
arteries branch from the M1 segment are of great importance
clinically, and their presence and preservation should be empha-
sized. Knowledge of these when dissecting along the M1, as
well as preservation with manipulation of this larger segment,
prevents damage. Larger named branches along this segment
include the anterior temporal and polar temporal arteries, either
of which can serve as bypass donor arteries if needed.
The MCA bifurcation, like the anterior communicating
artery complex, is variable. Classically, the bifurcation branches
into a superior and an inferior division, whereas in approxi-
mately 15% of patients a trifurcation is identified. Other pat-
terns are also seen, including separating into multiple small
branches. Generally, when a superior trunk is identified, it will
supply branches in the lateral frontobasal artery, prefrontal
sulcal artery, and precentral and central (rolandic) terminal
branches. The inferior trunk forms inferior temporal branches
(anterior, middle, and posterior), an angular branch, and often
two parietal branches (anterior and posterior). Variability is the
rule with terminal branches, and variances are expected. Iden-
tifying the vascular anatomy for a given patient is of particular
importance in patients with MCA pathology, as small branches
are often obscured from the surgeon’s view.
The Surgical Approach to Anterior
Circulation Aneurysms and General Tenets
The common aneurysms of the anterior circulation are typi-
cally related to the branch points of the named intracranial
vessels and include the cavernous carotid, ophthalmic and
superior hypophyseal, posterior communicating anterior cho-
roidal, and ICA blister and terminus aneurysms, anterior com-
municating artery and pericallosal aneurysms, and middle
 CHAPTER 17 Anterior Circulation Aneurysms 267

Paracentral A IIPA
SIPA Precuneal A
PMFA

IMFA

y
ter
Ar
al
AMFA

os
all
ric
Pe

A3-A5
A2
A1
CmaA

FpA LSAs
RAH

OfA
MCA

ACoA
PCoA

ICA

Figure 17.2 The anterior cerebral artery is divided into five segments, A1 through A5. A1 includes the
anteromedial central (medial lenticulostriate), the recurrent artery of Heubner (variable), and the anterior
communicating artery. A2 branches include the orbitofrontal artery (medial frontal basal) and the fronto-
polar artery. A3, also termed the pericallosal artery, gives rise to the callosal marginal artery and then
terminates as the internal parietal arteries (superior, inferior) and the precuneal artery. The callosal marginal
artery in turn branches into the medial frontal arteries (anterior, intermediate, posterior) and the paracentral
artery. A4 and A5 segments are the distal smaller branches, often named the callosal (supracallosal)
arteries.

cerebral artery and distal middle cerebral artery aneurysms.
The locations of aneurysms in the International Study of
Unruptured Intracranial Aneurysms (ISUIA) retrospective
cohort in patients without a history of subarachnoid hemor-
rhage (SAH) demonstrated that ICA and MCA aneurysms are
the most frequent.17
Prior to opening the dura, several points of emphasis should
be made, and although this applies to anterior circulation
aneurysms, it can be carried forward to all types of cerebro-
vascular surgery. Prior to opening the dura, communication
with anesthesia regarding the completion of administration of
osmolar agents such as mannitol should be discussed, along
with end tidal CO2 levels using effective neuroanesthesia tech-
niques. We typically administer 0.5 to 1 g/kg of mannitol on
both ruptured and unruptured cerebral aneurysm cases to aid
in brain relaxation, to minimize or eliminate retraction, and for
its neural protective benefits.18 Availability of neuroprotective
agents (eg, propofol or phenobarbital) in the room should be
ensured. Although rarely needed, we have our anesthesiolo-
gists prepared to administer adenosine to achieve temporary
cardiac arrest in the event of a catastrophic intraoperative
rupture. Although the bleeding of an unruptured aneurysm
is exceedingly rare upon dural opening, giant or atypically
adherent aneurysms are more susceptible to rupture. Ruptured
aneurysms are more likely to rerupture while opening the
dura because of the changes in pressure associated with this
opening. As such, the well-prepared aneurysm surgeon should
have several adjuncts available prior to opening the dura. The
microscope with the mouthpiece should be balanced, draped,
and the light source powered on. If the surgeon prefers to
use a chair, this should also be draped and positioned. The
aneurysm clips and microsurgical instruments should be open
and prepared; a temporary clip should be loaded and avail-
able. Although retractors should be avoided in routine surgery
268 PART 3 Vascular Neurosurgery

prerolandic A
postrolandic A

APBr

Prefrontal sulcal A PPBr

F
PTBr
LSAs
MTBr

Frontobasal A ATBr

ATA

M3 PTA
M2
M1 T

Figure 17.3 The middle cerebral artery is divided into four segments, M1 through M4. M1 includes
the medial and lateral lenticulostriates, the anterior temporal artery, the polar temporal artery, and, variably,
the uncal artery. The M2 branches include the frontal and temporal branches, and named branches from
these are considered M3 branches. The frontal branch includes the frontobasal artery, the prefrontal sulcal
artery, and the pre-/postrolandic arteries. The temporal branches include anterior, middle, and posterior
branches as well as the anterior and posterior parietal branches. M4 is composed of arterial branches
emerging from the named branches within the Sylvian fissure onto the convex surface of the hemisphere,
also known as the cortical segments.

whenever possible, the retractor system should be attached,
loaded, and positioned so that it can be utilized at a moment’s
notice if needed. For very large or proximal aneurysms, con-
sideration of carotid artery exposure in the neck should be
evaluated and discussed. The time required for even the most
efficient carotid artery exposure can be catastrophic with a
hemorrhage, in particular if only a single surgeon is scrubbed.
Lastly, the patient should have been “typed and crossed” for
blood, and depending on the hospital where the surgery is
being performed, either the blood bank should be notified
or the blood should be available in the room. Having these
general tenets in mind before opening the dura can change an
unexpected rupture from being a disaster to being a controlled
situation that can be addressed efficiently.
The subarachnoid space and its dissection are of paramount
importance for safe aneurysm dissection and treatment. In the
unruptured setting, this plane can provide a beautiful corridor
to the skull base and its contents, including the circle of Willis;
in contrast, in the ruptured aneurysm setting, this same space
is filled with blood and can present a challenge to safely
identify the normal and diseased vasculature. The subarach-
noid space is divided into cisterns, which are connected by
arachnoid membranes, and it is filled with cerebrospinal fluid
(CSF), leading from the cortical surface to the basilar cisterns.
By opening these planes, it allows egress of CSF, which pro-
vides intrinsic brain relaxation, and provides visualization of
the vascular anatomy. Having a working knowledge of the
cisterns and the vascular contents allows the neurosurgeon to
use the subarachnoid planes to their advantage. Careful dissec-
tion through the interconnected cisterns allows a surgical plan
to be executed while following the vascular tree to the aneu-
rysm and related vessels.
Subarachnoid dissection should be performed sharply,
beginning at the cortical surface. The Sylvian cistern contains
the M1 and its branches, as well as the origins of the lenticu-
lostriates, the temporopolar and anterior temporal arteries, the
MCA bifurcation, and the origins of its major branches. For
both the orbitozygomatic and pterional approaches, the Sylvian
fissure is best approached from the cortical surface and is
opened sharply from distal to proximal, using great care to

cA
post-Ro
Prefrontal sulcal A PP
F although they are applied to the Sylvian dissection and offer
PTBr
LSAs
MTBr
asal A * importance. Identification of the distal arterial branches in the
*
ATBr
ATA
+ priority. Having access to “proximal control” is not only a
PTA
T
Figure 17.4 The Sylvian fissure dissection with several important
tenets: the clear reflection of the veins inferiorly, with a focus on vein
preservation, and identification of the base of the fissure and the M2 seg-
ments (*). Atraumatic and retractor-less dissection should be the goal
whenever possible. Dissection follows the distal M2 segments proximally
to the middle cerebral artery bifurcation adjacent to the limen insula (+).
avoid injury to distal arterial branches and Sylvian veins19 (Fig.
17.4). We typically open this fissure distal to proximal, super-
ficial to deep, with the immediate goal of identifying the M2
branches, which can be followed to the M1 branch. It is
important to avoid the temptation to work through a narrow
corridor, but rather open the cortical surface along the entire
distance of the fissure, first in a superficial and then on a second
pass, a middle plane, and then conclude on a deep plane, where
the M2 vessels and its branches lie. The orientation of the
fissure will vary depending on the position of the head, but it
is invariably in an oblique-inferior direction. MCA aneurysms
within the Sylvian fissure, such as an MCA bifurcation aneu-
rysm, require an adaptation of this technique (see the Middle
Cerebral Artery Aneurysms section, presented later). Respect-
ing the Sylvian fissure also allows for safe passage along the
frontal and temporal lobes and avoids damage to the language
areas of the dominant hemisphere and the rolandic fissure.20
CHAPTER 17 Anterior Circulation Aneurysms 269
In addition, although the presence of a hematoma or subarach-
noid blood can be a determinant in some cases, in other cases
this can be followed and evacuated, allowing a more expedi-
tious exposure of the fissure. After an acute subarachnoid hem-
orrhage, the initial opening of the Sylvian fissure may be
challenging. Often, the thick subarachnoid blood can obscure
identification of the fissure itself. A useful technique is to use
a tuberculin syringe to inject air into the Sylvian fissure before
opening the cistern. The air will fill the subarachnoid spaces
and make the initial opening more straightforward.
Depending on the location of the aneurysm, a few other
general tenets can guide the surgeon with dissection, and
access to the circle of Willis, they can and should be applied
to most approaches. Having a clear understanding of the loca-
tion, morphology, and size of the aneurysm is of paramount
base of the fissure allows them to be followed proximally to
the larger trunk vessels. The extent of proximal dissection
should be guided by three principles. The identification of the
proximal artery in a perforator-free zone that can be safely and
temporarily occluded if desired or needed should be a high
fundamental tenet of cerebrovascular surgery, but it allows
unexpected ruptures to have the potential of salvage and
success. Second, the dissection should be adequate to relax the
brain and to provide a tension-free working zone that can
eliminate the need for retractors and optimize working angles.
Lastly, consideration should be given to a potential donor
vessel in the event a bypass is required. In some cases, a proxi-
mal artery can or will serve as a donor vessel for a bypass (eg,
anterior temporal artery), and if so, this should be exposed
adequately. Alternatively, the superficial temporal artery should
be preserved when possible during opening, particularly for
ICA and MCA aneurysms. The temptation to minimize the
dissection to the aneurysm and the immediate vessels in the
vein by hurriedly clipping the aneurysm because of the fear of
rupture should be avoided. For a majority of aneurysms that
are exposed using the transsylvian approach, exposure of the
opticocarotid cistern for both proximal vessel identification in
a perforator-free zone and the ability to open the basilar cis-
terns to allow egress of CSF should typically be considered. In
subarachnoid hemorrhage cases, we typically open the lamina
terminalis to allow further egress of CSF and lower the risk of
subsequent hydrocephalus in some patients.
The venous drainage pattern of the Sylvian fissure varies
tremendously, and although the unique anatomy of the venous
drainage itself is not the primary consideration with regard to
dissection, adaptation to the patient’s anatomy while reflecting
the veins temporally should be emphasized. In addition, the
preservation of the cerebral veins, although traditionally
regarded as of secondary importance, cannot be emphasized
enough. Kageyama and associates21 noted that the preservation
of cerebral veins was the single most important prognostic
factor contributing to morbidity in patients undergoing crani-
otomy for a cerebral aneurysm. This was later supported by
Spetzler and colleagues,22 who showed that patients with an
270 PART 3 Vascular Neurosurgery
altered superficial middle cerebral vein on postop angiogram
were more likely to have cerebral edema, and although these
and other studies have limitations, most experienced aneurysm
surgeons appreciate the importance of meticulous dissection
techniques and venous preservation.
A few additional nuances regarding dissection and exposure
should be emphasized. Dissecting on the perforator free area
of a vessel where a temporary clip may be applied is of supreme
importance. The undersurface of the M1 branch and the A1/
ICA terminus are to be respected and avoided unless absolutely
necessary. As the surgeon continues to work proximally, pro-
gressively identifying locations for temporary clips that avoid
these perforator zones allows for safe temporary occlusion if
necessary. Yasargil introduced the importance of sharp dissec-
tion; this technique, along with a meticulous, clear field,
should be emphasized. A microsuction, microscissors with a
sharp bayonetted forceps or bipolar cautery forceps, and a
Rhoton dissector are the most common instruments for Sylvian
fissure dissection and should be viewed as surgical “anchor”
instruments. The brain should be protected with Surgicel
(Ethicon, Inc, Somerville, New Jersey), moist cotton patties,
or Teflon, except the area that is immediately being dissected.
The use of surgical cotton balls or wisps placed within the
fissure allows for atraumatic dissection and dynamic retraction,
and these items serve as intrinsic hemostatic agents that maxi-
mize surgical efficiency.
Surgical dissection should be performed in a repeatable
pattern whenever possible. Using a stepwise approach allows
for different levels of efficiency and lessens the chance of missed
steps that may be critical to the outcome of the surgery. The
fissure dissection, followed by the preliminary and then the
final dissection in discrete steps, should be entertained. We
have found that it is less traumatic to avoid fixed retractors and
to instead use instruments for dynamic retraction. This is fol-
lowed by the clipping and final evaluation steps. The level of
organization and a stepwise approach will vary by surgeon, but
a patterned and precise approach should be utilized by all
skilled cerebrovascular surgeons.
Preliminary Dissection
As the Sylvian fissure (or interhemispheric fissure in the case
of pericallosal aneurysms) is efficiently and atraumatically
opened as noted previously, the preliminary dissection of the
aneurysm now begins. This consists of several steps and is
highly dependent on the location and angioarchitecture of the
aneurysm. During this preliminary dissection, the exact loca-
tion of the aneurysm is generally identified—the aneurysm
itself it not dissected at this point. The orientation of the dome
and adjacent vessels are identified. The provisional temporary
clip is now selected, and a trial of placing the clip on the
proximal segment is tested to ensure the proper clip has been
identified and that it has been loaded correctly. Often a paddy
is placed in line with this segment so that if the aneurysm
unexpectedly ruptures, this paddy can be followed to the proxi-
mal control site and a clip can be applied. With every move-
ment of the microscope onward, the proximal occlusion site
must be revisualized, mentally adjusting the trajectory to the
new angle. It is necessary to avoid the over-magnification of
angles where this site is obscured. Although distal control is
not frequently needed, ICA aneurysms (C6 and C7 segments)
can occasionally require distal control because of the robust
collateral blood flow available; if this is a concern, identifying
these distal control points prior to further dissection is of vital
importance. Although temporary vessel occlusion is an impor-
tant adjunct to aneurysm surgery, care should be exercised in
its use. Woetgen and colleagues found that during temporary
clip occlusion, there was a trend toward greater postoperative
ischemic injury and vasospasm in patients who underwent
temporary clipping for ruptured aneurysms, and greater ische-
mia trends in the MCA group with longer occlusion times.23
During this preliminary dissection, after the proximal
occlusion zones are identified and the location of the aneurysm
is generally identified, the orientation and associated vessels are
then identified and sharp dissection continues. With the ori-
entation and identification of the complex now completed, this
is often an opportunity to review necessary imaging by com-
paring and contrasting by memory or in real time the identi-
fied anatomy and angiographic anatomy. “It is said that if you
know your enemies and know yourself, you will not be imper-
iled in a hundred battles.”24 This is of particular importance
with identification of and exploring for associated vessels. As
one begins to dissect and appreciate the morphology of the
neck and the dome of the aneurysm during this preliminary
dissection, the “provisional aneurysm neck” is identified and a
provisional permanent clip is selected and loaded to allow for
potential clip application in the setting of an unexpected hem-
orrhage, although this should be avoided unless absolutely
necessary. Lastly, communication with the operating room
team, including the surgeon’s assistants, is important at this
juncture, and the scrub nurse should review anticipated instru-
ments. The team will often appreciate a moment of pause.
Final Dissection
Occasionally, the preliminary and final dissection can occur
simultaneously, but for the novice surgeon, they should be dis-
crete, deliberate, and precise steps. The final dissection involves
defining the exact neck and the precise trajectory needed for
ideal clip application. The small or adherent vessels should be
dissected off of the dome where necessary, but this step can be
avoided if it is not necessary to apply the clip without com-
promising the vessel. Only vessels that are likely in the path
of the clip blades, are at risk of occlusion because of torsion
of the neck or sac, or are otherwise at risk should be dissected
or freed. Very often a partial or intentional incomplete dissec-
tion will free the vessel enough to allow the clip to be safely
applied behind the vessel. The small surrounding vessels or
veins should be protected, as all too often they will obscure,
or begin to bleed and thereby obscure, the final views needed;
wisps of cotton are ideal for this final preparation. Sharp dissec-
tion is the rule, and this is often where inexperienced surgeons
will dissect inadequately, but it is indeed where meticulous
dissection is of paramount importance.

The final dissection may or may not include the dome of
the aneurysm; this will depend on the size, location, and pres-
ence of attached vessels and the overall location of the lesion.
Generally, the larger the aneurysm, the less likely the clipping
will benefit from dissection of the full dome, but there are
clear advantages of full manipulation and control of the entire
aneurysm. In much the same way, whether a temporary clip
is applied for this final dissection phase or clip application
is an individual decision. Doing so can lessen the anxiety of
final dissection to some extent, as well as reduce the tension
of the vessels or sac, which can simplify the final dissection
and clipping. Temporary occlusion, as has been noted, can
come with potential complications and occasionally a false
sense of security. Lastly, insonation with a micro-Doppler of
the exiting or distal vessels with attention to the tone and
character can be invaluable, and even with the advent of indo-
cyanine green (ICG) videoangiography the micro-Doppler
plays a vital role, which can be checked and rechecked and is
complementary to ICG. We typically also have the anesthesia
team prepare the ICG and place it “in line” but with firm
instructions not to inject until someone from the team has
heard specifically from the surgeon to inject the ICG at the
appropriate time.
Clipping
With proper preparation and exposure, clip application should
not be the most challenging part of the surgery, but clip selec-
tion and application are critical. Although there are specific
clip configurations for specific aneurysm locations, the ulti-
mate clip selection is highly individualized based on the angio-
architecture of the specific aneurysm. Considerations include
a construct that completely eliminates the aneurysm from the
circulation while maintaining patency of the parent vessels and
associated branches. In general, the shortest clip possible to
accomplish complete occlusion of the neck is best, to avoid
unintentional occlusion of normal vasculature beyond the
distal neck. We find that a temporary clip applied at this point
allows for a softening of the sac, and a final check with a dis-
sector can be completed to visualize the neck and associated
vessels. Once applied, the temporary clip is removed with
caution, first opening the blades without removing the clip to
ensure no unexpected bleeding is encountered; if there is bleed-
ing, reapplying the clip after identification of the source is
often required. Once the clip is applied, the length of the clip
tines should be explored immediately to be sure the neck is
completely secured and the clip does not compromise the sur-
rounding vasculature. Although exploration under the operat-
ing microscope is essential, external visualization is often
inadequate to determine patency of the parent vessel and
branches. This is particularly true of large aneurysms and those
with thick walls. A micro-Doppler, ICG videoangiography,
and intraoperative digital subtraction angiography (DSA) are
all useful adjuncts for reinsonation and to document complete
obliteration of the aneurysm and normal filling of the sur-
rounding vasculature. In a recent single center analysis compar-
ing intraoperative indocyanine green angiography (ICGA)
CHAPTER 17 Anterior Circulation Aneurysms 271
versus DSA, both modalities produced equally low rates of
unexpected aneurysm filling, parent vessel compromise, and
perioperative strokes, suggesting that ICGA may be an accept-
able replacement for intraoperative DSA in selected patients.25
Any imperfections should immediately be corrected using a
careful and deliberate move of readjusting the clip. Any remain-
ing dog-ears can usually be eliminated by clip readjustment or
the addition of another clip.
Although clip selection and clip patterns are challenging
and require experience and planning, a few principles should
be kept in mind. If the clip is felt to be imperfectly placed,
avoid the temptation to open it partially and move it; rather
make it a well-calculated maneuver. If the clip can be left in
place and a second clip can be safely applied to perfect the
construct, this option should be considered. Occasionally, a
small thin-walled neck or aneurysm remnant that was used to
reconstruct the vessel may bleed after the clip is applied; in this
case, placing a small piece of cotton under the tine of the clip
and capturing it with closing can provide a permanent and
immediate hemostasis, without having to occlude the neck
further.
Calcification or atherosclerosis of the neck should be con-
sidered and evaluated during the final dissection phase prior
to clipping whenever possible. If the clip does not purchase at
the intended closing site, repositioning the clip farther away
from the neck may allow additional purchase. The danger is
that the incorporated calcium may occlude the parent or the
distal vessels with manipulation. It also may make the effective
closure of the clip or obliteration of the aneurysm impossible.
Occasionally, novel clip strategies need to be incorporated or
booster clips that increase the closing force of the aneurysm
need to be used. A primary fenestrated clip with a second short
clip overlying the fenestration can also be used to increase the
closing force over a shorter individual clip segment. Experi-
enced surgeons occasionally will externally compress the neck
to break up the calcium in extreme situations. Bypassing a
diseased segment is rarely necessary but should be in the sur-
geon’s armamentarium.
Final Evaluation
Once the surgeon is satisfied with the initial evaluation of
the clip construct anatomically, by Doppler and then ICG,
a final evaluation should be done. The surgeon will ensure
that there are no unintended implications of the construct
on adjacent structures when brain is in situ and that there is
no unexpected rotation of the construct or expected hemor-
rhage from adjacent vessels with removal of the adjuncts. An
intraoperative angiogram is the gold standard approach to
ensure complete obliteration of the aneurysm and filling of
the normal vasculature. Distal emboli or other unexpected
complications from the angiogram should be weighed with
the importance of gaining diagnostic information regarding
the vascular anatomy of both the visualized and the nonvi-
sualized anatomy—something that is only possible with an
angiography.
272 PART 3 Vascular Neurosurgery
Anterior Circulation Aneurysm Subtypes
Each aneurysm has unique challenges. Knowledge of the
unique nuances of specific aneurysms and their pitfalls will
keep a well-prepared surgeon from avoiding common compli-
cations and will ideally improve the patient’s care and outcome.
Proximal Internal Carotid Artery Aneurysms
Cavernous segment aneurysms are unique in terms of natural
history and therapeutic options. Because these aneurysms are
extradural, they are associated with a benign natural history
and often require no treatment. When symptomatic, they are
most often treated by endovascular means in this era. Clinoidal
segment aneurysms lie between the two dural rings and are not
within the subarachnoid space unless they grow to such a size
that they pierce the dural ring. The ophthalmic segment of the
ICA may give rise to aneurysms at the origin of the ophthalmic
or superior hypophyseal arteries.
As noted previously, ophthalmic artery aneurysms arise
from the superior surface of the ICA just beyond the origin
of the ophthalmic artery (OA), following the expected linear
flow of the blood at the terminus of the carotid siphon. This
anatomically complex area deserves special mention and study,
as an understanding of this segment will facilitate its treat-
ment when needed. In approximately 10% of patients, the
OA branches more proximally, either from the cavernous
carotid or, more commonly, the clinoidal (C5) ICA. The SHA
branches arise medially and are slightly more distal than the
ophthalmic artery. The lateral component of the siphon flow
vector is the hemodynamic component of SHA aneurysms
as compared with the superior oriented vector seen with OA
aneurysms.
There are multiple anatomic nuances that make proximal
ICA aneurysms challenging to treat, and these should be con-
sidered with treatment planning. Proximal control of an oph-
thalmic segment aneurysm may be obtained at the clinoidal
segment after removal of the anterior clinoid process, at the
petrous segment, or by exposing the cervical carotid. The cervi-
cal carotid artery should be prepped and within the field in all
proximal carotid aneurysm cases, and it is prudent, but not
necessary, to consider opening the neck at the beginning of the
case, particularly for a novice surgeon. If the neck is opened,
a double vessel loop should be placed around the cervical ICA
and loosely attached. The plan of opening the neck only after
proximal control is needed should be avoided; a small cervical
incision heals in most patients, and the exposure takes little
time. For clinoidal segment aneurysms, the clinoidal segment
of the ICA may not be available for proximal control and the
petrous or cervical carotid should be considered.
When operating on proximal ICA aneurysms, the surgeon
should always be prepared to remove the anterior clinoid
process for adequate exposure of aneurysms involving the cli-
noidal or OA segment. The anterior clinoid process is a bony
ridge, forming the roof of the optic canal, and is attached
below by the optic strut. Understanding the relation of the
clinoid with the ICA and optic nerve is essential for the safe
treatment of proximal ICA aneurysms. Although extradural
removal of the clinoid is described in oncologic approaches,
because of the possibility of adherence and the inadvertent
rupture of proximal ICA aneurysms, this action should be
avoided. During extradural dissection, we aggressively remove
the lesser wing of the sphenoid and the posterior third of the
orbit, leaving the remainder of the anterior clinoid process
for the intradural portion of the procedure. After opening
the dura in an arc from the medial point of the entry of
the optic nerve to a point lateral to the ICA (distal dural
ring), this is reflected inferiorly over the ICA and optic nerve
(Fig. 17.5). Although we have used a diamond-bit drill and
a 1-mm Kerrison rongeur in the past, we now prefer to use
an ultrasonic aspirator to remove the roof of the optic nerve
and the anterior clinoid process. The optic strut now remains
between the optic nerve and the carotid artery. There is often
cavernous venous bleeding at this phase that can be controlled
with powered procoagulants. The optic strut is then either
egg shelled or snapped off, depending on the location of the
aneurysm and the thickness of the strut. Waxing of the bone
edges prevents the infrequent but nefarious CSF leak at this
site. With these three steps completed, the distal dural ring
and falciform ligament can then be opened sharply to expose
the clinoidal segment of the ICA, which exposes aneurysms of
that segment and provides proximal control and exposure of
the proximal neck of OA and SHA aneurysms. If the dural ring
is being opened to expose a SHA aneurysm, the ring opening
should be extended circumferentially as much as possible to
allow mobilization and visualization of the aneurysm on the
ventral-medial surface of the ICA. Additionally, opening of
the falciform ligament over the optic nerve allows mobilization
of the nerve and decompresses the tether that can sometimes
be seen with ophthalmic segment aneurysms. If the proximal
neck of the aneurysm is well visualized, removal of the anterior
clinoid process is not necessary and potential morbidity may
be avoided.
A proximal temporary clip location is now identified. If one
is using the clinoidal segment for proximal control, a mini-
temporary clip to maximize visualization is preferred if possi-
ble. Clip selection will depend on the origin of the aneurysm
and its specific configuration. In general, the ideal clip for an
ophthalmic artery aneurysm is a side-angled clip that ends up
with the blades parallel to the axis of the ICA. Superior
hypophyseal aneurysms typically require a fenestrated clip,
where the fenestration is used to reconstruct the lumen of the
ICA with the blades on the ventromedial surface of the ICA
to obliterate the aneurysm. Preliminary dissection should also
address the optic nerve and tether points, although the manip-
ulation of the nerve should be minimized (Fig. 17.6).
Final dissection should proceed with caution. SHA aneu-
rysms are challenging because the normal carotid artery is
between the surgeon and the neck of the aneurysm on the
ventral surface of the ICA and because the optic nerve overlays
the superior portion of the ICA at this level. Mobilization of
the optic nerve can minimize trauma to this nerve if manipula-
tion is necessary and where the value of removing the clinoid
and optic canal roof can carry significant advantages.
 CHAPTER 17 Anterior Circulation Aneurysms 273

Oph A

Incision

CN II
Optic
strut

ICA

A1

M1
A B

Optic strut

Distal
dural ring

C
Figure 17.5 The anatomy of a right-sided intradural clinoidectomy. (A) Sharply incise the dura in a
T-shaped manner over the anterior clinoid process (ACP), with a medial extension past the optic nerve
(II). (B) Diamond-bit drilling of the anterior clinoid process occurs under continuous irrigation until the roof
of the optic canal, the orbital apex, and the optic strut are exposed. (C) The final work after “egg shelling”
the bone can be done with a microcurette or a 1-mm Kerrison rongeur. With the final bone removal,
cavernous venous bleeding can be tamponaded with hemostatic agents. With the C6 ophthalmic segment
now fully exposed, identification of the proximal carotid and neck of the aneurysm is now possible. Resec-
tion of further components of the distal dural ring is now possible, if needed.
274 PART 3 Vascular Neurosurgery
Oph A
Proximal
dural ring
C5
C6 Distal
dural ring
An
ICA
A1
M1
Figure 17.6 Unruptured anatomy of ophthalmic aneurysm, internal
carotid artery, and optic nerve. The three-dimensional anatomy of the
proximal and distal dural ring is shown, with the origin of the ophthalmic
artery. The distal dural ring and the relationship of the ophthalmic artery
and aneurysm are variable and often best defined in surgery.
Posterior Communicating and Anterior
Choroidal Artery Aneurysms
The posterior communicating artery (PCOM) and anterior
choroidal artery (ACH) branch laterally from the communi-
cating segment of the ICA, prior to its bifurcation into M1
and A1. They are intimately associated with each other. The
location of the ACH is often immediately distal and adjacent
to the takeoff of the PCOM and needs to be identified and
protected with every PCOM aneurysm that is surgically
explored and ligated. Although the most common site of origin
of the ACH is from the ICA itself, normal variants of branch-
ing include origin from the PCOM, the proximal M1, or the
ICA bifurcation itself. The course of the proximal ACH is
posteromedial behind the ICA and is associated with the
medial aspect of the uncus. The second anatomic consideration
of the PCOM is the presence of a fetal PCOM, whereby the
P1 is functionally absent and as such the fetal PCOM supplies
not only the thalamoperforators along its course but also the
ipsilateral P2–P4 segments. By losing the redundancy of the
circle of Willis with this anatomic variant, the importance of
preservation of a fetal PCOM becomes the highest priority.
A transsylvian approach is undertaken in the standard
manner with several additional considerations. The PCOM
aneurysm can be, and should be assumed to be, adherent to
the free edge of the tentorium or the medial temporal lobe,
and it lies immediately adjacent to the opticocarotid triangle,
so that the surgeon dissects the fissure using a trajectory that
is frontally oriented while minimizing traction on the temporal
lobe. Second, dissecting through the fissure and following the
M1 branch to the bifurcation, and maintaining the dissection
on the cephalad rather than the lateral aspect of the vessel, are
vital steps to complete while identifying the opticocarotid tri-
angle contents as initial objectives. On rare occasions, the
anterior clinoid process may obscure a PCOM aneurysm, and
proximal control at the cervical carotid with or without removal
of the anterior clinoid process may be necessary. The prelimi-
nary dissection should seek to identify the ACH; ideally pre-
operative imaging will guide the surgeon with regard to its
association with the neck of the aneurysm. Occasionally, the
table or microscope will need to be changed to a more lateral-
medial trajectory at this point. Identification of both proximal
and distal control sites should be completed at this juncture,
and the former can be occasionally challenging as the optic
nerve and the clinoid process are often blocking clear access.
Placing a temporary clip, if needed, within the immediate
vicinity of the aneurysm typically will mitigate any advantage
of using this. Opening the falciform ligament just lateral and
parallel to the optic nerve enlarges the landing zone for a tem-
porary clip, as can removing the anterior clinoid process if
needed.
The final dissection should seek to isolate and protect the
ACH if not already done. This will involve dissection of the
neck and specifically determining whether the ACH is coming
entirely from the PCOM or whether it also involves the ICA
proper. Identification of the oculomotor nerve during the final
dissection will minimize trauma and avoid unintended injury
(Fig. 17.7). A fixed retractor is rarely required, but if needed,
placing it only on the frontal lobe, parallel to the fissure and
the optic nerve, is preferred. Final dissection of first the distal
neck and the exact location of the ACH, and then proximally,
to identify the PCOM, and its relation with the ICA and the
aneurysm, is then completed. Finally, the plane between the
PCOM and the aneurysm itself is defined using a Rhoton dis-
sector. Use great care to avoid manipulation or dissection of
the dome of the aneurysm, as these are often adherent to the
tentorium or the parenchyma at this location. Preclip Doppler
of the ACH and the PCOM, which is often best done medial
to the carotid, is of paramount importance, particularly in fetal
PCOM aneurysms.
Clipping of PCOM aneurysms is typically done with a
slightly curved clip, with the proximal blade being placed
proximally along the PCOM and at the junction between the
vessel and the aneurysm, visualizing this as much as possible
during this maneuver, as well as advancing the distal blade
between under direct visualization between the PCOM and
the ACH. The slight curve of the clip helps eliminate a
“dog-ear” adjacent to the ICA. A final rotation maneuver drop-
ping the surgeon’s hand toward the globe minimizes the likeli-
hood that the distal blades will pinch the distal PCOM and
will also make the clip more parallel to the ICA. The ACH
and the distal blades should be inspected immediately. Explo-
ration of the ventral surface of the ICA to ensure a remnant is
 CHAPTER 17 Anterior Circulation Aneurysms 275

Tentorium

Temporal
CN II lobe

ICA

ACoA
PCoA An

A1

M1
M2

M2

Frontal
lobe

Figure 17.7 A posterior communicating artery (PCOM) aneurysm. The orientation of the PCOM is
shown, originating lateral to the internal carotid artery (ICA), and the coursing posterior and dorsal to the
artery. Distal identification can often be done medial to the ICA. The anterior choroidal should always be
identified before the final dissection of a PCOM aneurysm, as its preservation is paramount. AcoA, anterior
choroidal artery.

not left that is obscured by the ICA is of paramount impor-
tance. ICGA will identify the distal PCOM and ACH, although
intraoperative angiograms typically produce high-yield results
in PCOM cases, particularly for fetal PCOM aneurysms.
The exposure and clipping of ACH aneurysms is performed
in much the same manner as for PCOM aneurysms, with clip
selection being dictated by the particular angioarchitecture of
the aneurysm.
Middle Cerebral Artery Aneurysms
The middle cerebral artery (MCA) begins after the bifurcation
of the ICA to the M1 and the anterior cerebral artery (ACA).
The M1 segment steeply follows the sphenoid ridge in the base
of the Sylvian fissure for a variable length, bifurcating into an
inferior and superior trunk, the M2 branches. The nature of
this bifurcation is highly variable, with a trifurcation occurring
in nearly 15% of patients.26 The lenticulostriate vessels that
branch from the M1 supply the deep structures of the anterior
perforated substance. Anatomic variants and the configuration
of the bifurcation should be closely studied on preoperative
imaging.
Sylvian fissure dissection needs to be modified for an MCA
bifurcation aneurysm, as the aneurysm can be encountered
with the dissection of the fissure before adequate proximal
control or brain relaxation/dissection is completed. Preserva-
tion of the superficial temporal artery is generally practiced for
MCA lesions, as a bypass can be safely and effectively per-
formed if needed. Generally speaking, one of two strategies for
fissure dissection can be used. The first approach of MCA
dissection and exposure is a superficial dissection technique,
opening the arachnoid over the fissure to begin the exposure
of the fissure but working above the anticipated location of the
aneurysm, following the sphenoid ridge proximally to the opti-
cocarotid cistern in a superficial plane—essentially just opening
the first layer of the Sylvian fissure. By opening over the optic
276 PART 3 Vascular Neurosurgery

nerve in this manner, the opticocarotid cistern is opened and
CSF is drained, allowing the brain to relax. The ICA can then
be explored for a proximal control location, typically at the
M1 segment. Once the initial proximal control has been estab-
lished, dissection can progress distally along the ICA to the
bifurcation and the M1, where a preferred temporary clip
landing zone should be identified and mentally marked,
making sure there are no perforators in danger with the M1
temporary clip location, typically as distal as possible on the
M1 to avoid occlusion of the lenticulostriates. Dissection then
proceeds distally along the M1 to identify the bifurcation
proximal to distal. The second approach for MCA dissection
and exposure is the deep approach, dissecting beneath the
bifurcation and the aneurysm complex to identify the distal
M1. Once proximal control is identified, one can then dissect
through the full depth of the fissure, complete the dissection
of the superficial fissure, and expose the aneurysm complex
fully. Although this approach works well for aneurysms that
are not at the base of the fissure, the pitfalls of this “deep”
approach are several. It can prematurely expose the aneurysm
before adequate proximal control is achieved, it can put the
lenticulostriate vessels at danger if one is careless with dissec-
tion, and it can create a narrow corridor of dissection until the
M1 is exposed; as such this deep approach should be used only
by more experienced surgeons or for superficial aneurysms.
Regardless of the dissection approach, the importance of
opening the fissure widely before beginning the preliminary
dissection should be emphasized.
Preliminary dissection for MCA aneurysms includes iden-
tification of the proximal control point and understanding the
orientation of the aneurysm dome, neck, and parent vessel
(Fig. 17.8A). With MCA aneurysms this often needs to be
correlated with preoperative imaging and mentally adjusted to
the operative field. Although some MCA aneurysms are easily
dissected free from the surrounding parenchyma, many MCA
aneurysms often have a small opercular branch, which is adher-
ent or obscured on the back side. Lastly, understanding the
clip angle and application so that the blades of the clip do not

Tentorium

CN II
CN II
Temporal Temporal
ICA lobe lobe
PCoA PCoA ICA

ACoA

A1 A1
M1 M1

An An

M2 M2
M2

Frontal Frontal
lobe lobe

A B

Figure 17.8 A middle cerebral artery (MCA) bifurcation aneurysm. (A) The preliminary dissection of an
MCA aneurysm should focus on identification of proximal control (typically a perforator-free zone of the
M1) and the confirmation of the three-dimensional anatomy of the vessels and aneurysm. Determination
of whether the dome needs to be dissected should also be done preliminarily. (B) The second figure in
this series with final dissection of an MCA bifurcation aneurysm and clip placement. Final dissection of
the aneurysm should be done with a provisional clip on standby. Determination of temporary proximal
occlusion should also be done at this juncture as well as final identification of branches immediately at
risk. If micro-Doppler is used, performing a preclip insonation of the distal vessels can be helpful.

PCoA
ACoA
ICA
A1 M1
An
M2 M2
C cation. After the bifurcation of the MCA and the ACA, the
Figure 17.8, cont’d (C) The clipped aneurysm.
compromise the origin of the M2 branches is of utmost
importance.
The final dissection around the MCA aneurysm should be
done sharply (Fig. 17.8B). Because of the ease of temporary
clip placement with these lesions, we often occlude them tem-
porarily to soften the dome and complete the dissection. MCA
aneurysms often have broad necks, and not infrequently they
incorporate the neck or sac into one of the distal vessels at the
neck, giving the appearance of a broader-still neck. The impor-
tance of identifying the actual neck is that it will allow an
accurate clipping of the aneurysm but also will minimize the
folding of normal parent artery into the clip construct. Doppler
of the M2 branches and associated smaller branches should
always be performed.
The clipping of an MCA aneurysm should be done in the
same manner as others with several nuances. Because of the
aforementioned broad neck that is commonly encountered,
stenosis of the parent vessel after clipping can be monitored by
clipping a softened aneurysm with a clip slightly higher than
usual so that as it closes it will incorporate the neck and recon-
struct the parent vessel. Torsion of clip constructs that can
CHAPTER 17 Anterior Circulation Aneurysms 277
cause distal vessel stenosis or occlusion must be carefully
observed during the clipping, and because of the complexity
of many MCA aneurysms, a multitude of clip constructs may
be possible. Generally, placing the clip and addressing the
distal neck of the aneurysm allows additional clips to be placed
more proximally to complete the clipping. Surgeons should
avoid the temptation to have a single clip reconstruct anything
but the most straightforward aneurysm. As noted previously,
calcification with MCA aneurysms is common and can chal-
lenge even the most skilled surgeon. Because of the full expo-
sure of these aneurysms, once one of them has been clipped,
explored, and insonated with a Doppler, indocyanine green
videoangiography and intraoperative angiography will docu-
ment complete obliteration and preservation of the normal
vasculature.
Anterior Communicating Artery Aneurysms
Selecting the side of approach to ACOMM aneurysms deserves
attention, as they can typically be approached from either the
left or the right. Dominance of the A1 and overall orientation
of the complex can favor one side over the other, as well as the
surgeon’s preference. For elective cases, some advocate a right-
sided approach unless there are clear reasons to approach from
the contralateral side because of the eloquence of the left
hemisphere. The transsylvian approach and fissure dissection
is performed in a similar manner for ACOMM aneurysms as
other approaches, and an ultimate lateral-to-medial trajectory
is preferred. Once the opticocarotid cistern is identified and
opened, the ICA is then followed posteriorly to the ICA bifur-
A1 branch travels medially and somewhat anteriorly to the
ACOMM complex. From there, also supplied by the contra-
lateral A1 and through the communicating artery, the most
ventral aspect of the circle of Willis, the vessels then move
distally as paired A2. Complete dissection of the ACOMM
complex requires the identification of 12 named vessels: paired
A1 and A2 segments, ipsilateral and contralateral recurrent
arteries of Heubner, and the communicating segment itself.14
Other branches include the associated A1 perforators and the
bilateral orbitofrontal and frontal polar arteries, but they are
infrequently involved by the aneurysm. Identification of the
first seven is of great importance in every case. The identifica-
tion of the recurrent artery of Heubner can be challenging and
is typically medially to laterally oriented from the distal A1.
Not uncommonly, the origin is proximal A2 or the communi-
cating segment itself, but as a rule of thumb, it is almost always
identified immediately adjacent to the ACOMM. Second, the
perforators from the distal A1 and the ACOMM should be
preserved, and they are a potential source of significant mor-
bidity associated with the treatment of ACOMM aneurysms.
Once the A1 has been identified above the optic nerve, the
first provisional proximal temporary clip landing zone is iden-
tified. Before dissecting further, the arachnoid that is ventral
to the frontal lobe is also divided with the goal of identifying
the contralateral optic nerve and allowing the frontal lobe to
fall away from the skull base, using gravity to aid in retraction.
278 PART 3 Vascular Neurosurgery

Preliminary dissection then proceeds along the A1, dividing
additional arachnoid membranes along the length. Depending
on the trajectory of the ACOMM aneurysm, a number of
decisions have to be made at this point (Fig. 17.9A). In com-
parison to MCA aneurysms where one has almost certain
access to all branches at this juncture, the dissection before
clipping does not necessarily reveal all afferent and efferent
vessels. Preoperative planning and understanding of the orien-
tation and the expectation of which vessels may be obscured
will be helpful. To add to the challenges of ACOMM aneu-
rysms, there is almost invariably a rotational component to the
complex, often dictated by the dominant artery and the flow
trajectory.27 There are a multitude of variables that will cause
significant variations, and the surgeon should be comfortable
with the 3D interpretation of the preoperative imaging to
facilitate final anatomic identification. Aneurysms that are
pointing superiorly or posteriorly will allow the dissection to
be carried beneath the complex to the contralateral A1 and
recurrent artery of Heubner, thereby identifying the paired A1,
paired recurrent arteries, and ipsilateral A2 at a minimum. This
also allows a contralateral provisional landing zone for a
temporary clip on the contralateral A1. It is tempting at this
time to move forward with further dissection, but both recur-
rent arteries of Heubner must be identified if at all possible.
Regardless, during this preliminary dissection, following the
ipsilateral A1 cephalad within the interhemispheric fissure to
the A2 is now done. Again, depending on the orientation of
the aneurysm, the contralateral A2 may also be visualized
above the aneurysm complex at this site. Although ultimate
identification is necessary, not all branches may be identified
prior to clip application. Typically, either the contralateral A1
or the contralateral A2 can be identified prior to final dissec-
tion; often both cannot. Lesions that are pointed anterior or
inferior are much more straightforward for these reasons.
Resection of the gyrus rectus should be undertaken only if
necessary and with care and consideration to what is to be
gained. This is most often necessary for aneurysms pointing
posteriorly. The gyrus rectus is identified immediately medial
to the olfactory tract and is best resected using a microdissector
and suction technique to efficiently remove this, leaving the
arachnoid of the interhemispheric fissure overlying the vessels
in place. This arachnoid is then opened deliberately using great

Frontal
Frontal CN II lobe CN II
lobe RAH

A1 A1
A2
CN II CN II

An
A2 ACoA

RAH

A1 ICA A1 ICA

Aneurysm
neck
M1 M1
A B
Figure 17.9 Anterior communicating aneurysm. (A) Preliminary dissection of an ACOMM aneurysm
should focus on proper orientation of the aneurysm and identification of the contralateral A1 for proximal
control, and ipsilateral A1 and A2. (B) Final dissection of an ACOMM complex with base and neck well
exposed, and potentially contralateral A2 and recurrent artery of Heubner identified. The final dissection
of an ACOMM aneurysm should focus on final delineation of the neck and dissection of adherent vessels,
as well as identification of contralateral vessels. Occasionally, because of the size or morphology of the
aneurysm, definitive identification of the distal vessels cannot be done until after the aneurysm is clipped.
Some surgeons will opt to place a proximal contralateral A1 clip during final dissection.

RAH
A2
A1
An
A2
ACoA
RAH
A1
C Pericallosal Aneurysms
Figure 17.9, cont’d (C) Status postclipping showing distal vessels
and exploration of the aneurysm. Immediately after clipping, the proximal
and distal vessels should be visually inspected.
care to preserve the perforators and the recurrent artery of
Heubner, which lie immediately beneath it. This maneuver
typically exposes the ipsilateral A1 and both A2s. While avoid-
ing dissecting the neck during this preliminary dissection stage,
a clear understanding and localization of the contralateral A2,
when possible, is important, as the junction between this and
the contralateral A1/A2/communicatory segment is important
for successful and safe clipping of an ACOMM aneurysm. This
technique of localization of the contralateral A2 above the
complex can be used even for superior projecting aneurysms
that often obscure this vessel.
During this final phase, we generally begin by identifying
the perforators at risk, in particular along the posterior aspect
of the communicating artery, and then focusing on first the
contralateral neck and then the ipsilateral neck (Fig. 17.9B).
At this phase, if the contralateral A1 can be identified and the
recurrent artery of Heubner can be safely avoided, consider-
ation of a contralateral temporary clip can be entertained. By
placing the temporary clip out of the field of direct dissection,
one has typically more straightforward access to the ipsilateral
A1 for temporary clipping if needed, whereas if one has
CHAPTER 17 Anterior Circulation Aneurysms 279
hemorrhage during the final dissection or clip application,
then safe identification of the contralateral A1 can oftentimes
be challenging. With downward or anterior-directed aneu-
rysms, temporary clipping of the contralateral A1 can be more
challenging but is less often necessary.
Clip application of the ACOMM can be challenging
because of the narrow corridor one is working with, as
well as accounting for the invariable rotational component of
ACOMM aneurysm complexes. Also, as noted, the final dis-
section and visualization of vessels with these lesions will some-
times occur late during the clipping process. Maintaining the
clip blades parallel with the communicator minimizes rem-
nants and torque on the complex and lessens potential injury
to perforators (Fig. 17.9C). Using the blades as microretractors
during the clipping process maximizes the corridors visualized
during clipping. ACOMM aneurysms that point posteriorly
typically require the use of fenestrated clips, with the fenestra-
tion encompassing the ipsilateral A2 and the blades avoiding
compromise of the contralateral A1–A2 junction. The contra-
lateral A2, then the contralateral A1 and the recurrent artery
of Heubner, the communicating artery perforators, and then
the ipsilateral vessels should be visualized during the final clip-
ping and manipulation process. Insonation of the major vessels
with a micro-Doppler and identification of the branches listed
earlier are then completed after the aneurysm is secure. ICGA
can be useful for identifying flow, in particular in the recurrent
artery of Heubner and the contralateral A2. Intraoperative
angiograms are high yield for ACOMM aneurysms in our
experience.28
The pericallosal artery begins as A2 segments from the com-
municating segment, branching to A3 at the rostrum of the
corpus callosum, and then to A4 in the horizontal segment;
distal branches are A5 and are infrequently involved. The bifur-
cation of the pericallosal artery, the arterial branch that courses
along the corpus callosum, and the callosomarginal artery,
which courses along the cingulate sulcus, is the most common
location of pericallosal aneurysms, but both the native arte-
rial anatomy and the location of aneurysms are highly vari-
able. For this reason, dissection and arterial dissection can be
challenging.
Differing from the remaining aneurysms of the anterior
circulation that can be addressed by a transsylvian approach
using either a pterional or orbitozygomatic approach, perical-
losal aneurysms are usually accessed with the interhemispheric
approach. Because the prepared distal anterior cerebral arteries
are intimately associated with each other within the interhemi-
spheric fissure, the overwhelming majority of pericallosal aneu-
rysms can be approached from the right side. Patient positioning
is counterintuitive, with the head in a lateral position and the
right side of the head down to use gravity to allow the frontal
lobe to fall away from the falx. The head is parallel to the floor
with the vertex angled upward so that the surgeon has a direct
view down the corridor of the falx. Pericallosal aneurysms can
occasionally benefit from stereotactic navigation for the novice
280 PART 3 Vascular Neurosurgery
surgeon, as this can facilitate the trajectory of the approach and
general location of the aneurysm. In general, the craniotomy
is placed two-thirds anterior to the coronal suture and one-
third behind, with a rectangular craniotomy extending over the
superior sagittal sinus. The importance of being on, rather than
adjacent to, the sinus should be emphasized, as the surgeon
should be able to open the dura to the sinus and have a trajec-
tory that allows a view down the falx; angles away from this
trajectory will significantly limit deep views and, importantly,
increase the need for retractors. The positioning of this crani-
otomy can be adjusted, but the emphasis of the forward posi-
tioning of the craniotomy and the forward, deep surgical
trajectory is the most common pitfall of the initial approach.
We prefer a relatively large craniotomy to select a trajectory
that avoids injury to any of the bridging veins to the superior
sagittal sinus. Thrombosis or injury to the draining veins from
the frontal lobe to the superior sagittal sinus can be devastat-
ing. All attempts should be made to protect them and work
around them. We usually place a piece of Gelfoam soaked in
heparin on the larger veins to prevent thrombosis. The heparin
is absorbed through the venous wall, providing local antico-
agulation. The initial approach and dissection through the
subdural space proceeds to the corpus callosum, and the paired
pericallosal arteries are identified.
The preliminary dissection follows the pericallosal arteries
proximally toward the rostrum of the corpus callosum (Fig.
17.10). The use of cotton balls moving forward can provide
focal retraction as necessary. This dissection can be perilous
with ruptured aneurysms, as the clot or dome may be adherent
to the brain surface; as such, over distraction should be
Falx
SSS
Figure 17.10 Positioning of a pericallosal aneurysm. The counterintuitive positioning of a midline
pericallosal aneurysm, with the pathologic side on the downward hemisphere. By using gravity to assist
with retraction, the exposure is facilitated.
minimized whenever possible during the approach. Following
the pericallosal arteries proximally will identify the distal A2
segment, just prior to the bifurcation of the pericallosal and
callosomarginal arteries, the most common location for these
aneurysms. This is an ideal site for proximal control and should
be evaluated to confirm that this is indeed the affected vessel,
not its contralateral counterpart. Working more proximally
than this on the A2 is challenging because of the depth and
angle of the field; as such, a frontal approach is favored for
these more proximal aneurysms.
The final dissection involves identification of the proximal
and distal ipsilateral vessels (Figs. 17.10 and 17.11). It is not
uncommon to have several vessels adherent to the aneurysm
complex that need to be ultimately dissected and preserved.
Similar to ACOMM aneurysms, having a three-dimensional
image of the ipsilateral and contralateral vessels is important.
We find that if the contralateral vessels can be exposed and
freed during this dissection, a patty or wisp of cotton can be
placed over the contralateral vessels to effectively isolate them
out of the immediate field. Preoperative imaging can often
allow the surgeon to appreciate the exact location of the neck,
so that dome dissection can be minimized. Before clipping,
with pericallosal aneurysms there is often adequate room for a
temporary clip, and this can facilitate the final dissection,
which is often challenging because of the depth of the field
and surgeon’s orientation, which is often overhead angle.
Invariably, there is an early branch that should be identified
and dissected if necessary. Doppler pre- and postclipping of
both ipsi- and contralateral vessels will allow immediate feed-
back of distal occlusions, and ICGA and intraoperative DSA
PcaA SSS
CC
An
PcaA
 CHAPTER 17 Anterior Circulation Aneurysms 281

LPcaA

CC
An

RPcaA

Figure 17.11 Pericallosal aneurysm. The A3 branches should be followed proximally, ensuring that
the appropriate vessels have been identified. Because of individual anatomy, identification of bilateral
vessels can ensure that one does not follow the incorrect vessel to the aneurysm. Although not often
done, stereotactic navigation can be useful to identify the correct trajectory. Following the corpus callosum
around the genu can often identify the proximal vessel. After clipping, often with a fenestrated clip, the
distal branches are frequently at risk with these lesions. Confirming adequate distal flow is paramount.

will confirm complete obliteration of the aneurysm and normal
filling of the surrounding vasculature.
Selected Key References
Bouthillier A, van Loveren HR, Keller JT. Segments of the internal
carotid artery: a new classification. Neurosurgery. 1996;38(3):425-432,
discussion 432-3.
Day AL. Aneurysms of the ophthalmic segment. A clinical and anatomi-
cal analysis. J Neurosurg. 1990;72(5):677-691.
Dean BL, Wallace RC, Zabramski JM, et al. Incidence of superficial
sylvian vein compromise and postoperative effects on CT imaging
after surgical clipping of middle cerebral artery aneurysms. AJNR Am
J Neuroradiol. 2005;26(8):2019-2026.
International Study of Unruptured Intracranial Aneurysms Investigators.
Unruptured intracranial aneurysms–risk of rupture and risks of surgi-
cal intervention. N Engl J Med. 1998;339(24):1725-1733.
Kassell NF, Torner JC, Haley EC Jr, et al. The International Cooperative
Study on the Timing of Aneurysm Surgery. Part 1: Overall manage-
ment results. J Neurosurg. 1990;73(1):18-36.
Lawton MT. Seven Aneurysms: Tenets and Techniques for Clipping. New
York: Thieme Medical Publishers; 2010.
Menghini VV, Brown RD Jr, Sicks JD, et al. Clinical manifestations and
survival rates among patients with saccular intracranial aneurysms:
population-based study in Olmsted County, Minnesota, 1965 to
1995. Neurosurgery. 2001;49(2):251-256, discussion 256-8.
Osborne AG. Diagnostic Cerebral Angiography. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, Wolters Kluwer; 1999.
Rhoton AL Jr, Perlmutter D. Microsurgical anatomy of anterior com-
municating artery aneurysms. Neurol Res. 1980;2(3-4):217-251.
Schievink WI. Genetics and aneurysm formation. Neurosurg Clin N Am.
1998;9(3):485-495.
Tang G, Cawley CM, Dion JE, et al. Intraoperative angiography during
aneurysm surgery: a prospective evaluation of efficacy. J Neurosurg.
2002;96(6):993-999.
Please go to ExpertConsult.com to view the complete list of references.

References
1. Brown RD. Seminars in Neurology. New York: Thieme Medical
Publishers; 2010.
2. Vlak MH, Algra A, Brandenburg R, et al. Prevalence of unruptured
intracranial aneurysms, with emphasis on sex, age, comorbidity,
country, and time period: a systematic review and meta-analysis.
Lancet Neurol. 2011;10(7):626-636.
3. Caranci F, Briganti F, Cirillo L, et al. Epidemiology and genetics of
intracranial aneurysms. Eur J Radiol. 2013;82(10):1598-1605.
4. Maher CO, Piepgras DG, Brown RD Jr, et al. Cerebrovascular
manifestations in 321 cases of hereditary hemorrhagic telangiectasia.
Stroke. 2001;32(4):877-882.
5. Schievink WI. Genetics and aneurysm formation. Neurosurg Clin N
Am. 1998;9(3):485-495.
6. Schievink WI, Riedinger M, Maya MM. Frequency of incidental
intracranial aneurysms in neurofibromatosis type 1. Am J Med Genet
A. 2005;134A(1):45-48.
7. Schievink WI. Marfan syndrome and intracranial aneurysms. Stroke.
1999;30(12):2767-2768.
8. Kassell NF, Torner JC, Haley EC Jr, et al. The International Coop-
erative Study on the Timing of Aneurysm Surgery. Part 1: Overall
management results. J Neurosurg. 1990;73(1):18-36.
9. Menghini VV, Brown RD Jr, Sicks JD, et al. Clinical manifesta-
tions and survival rates among patients with saccular intracranial
aneurysms: population-based study in Olmsted County, Minnesota,
1965 to 1995. Neurosurgery. 2001;49(2):251-256, discussion 256-8.
10. Gibbs GF, Huston J 3rd, Bernstein MA, et al. 3.0-Tesla MR
angiography of intracranial aneurysms: comparison of time-of-
flight and contrast-enhanced techniques. J Magn Reson Imaging.
2005;21(2):97-102.
11. Schwartz RB, Tice HM, Hooten SM, et al. Evaluation of cerebral
aneurysms with helical CT: correlation with conventional angiogra-
phy and MR angiography. Radiology. 1994;192(3):717-722.
12. Osborne AG. Diagnostic Cerebral Angiography. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, Wolters Kluwer; 1999.
13. Bouthillier A, van Loveren HR, Keller JT. Segments of the internal
carotid artery: a new classification. Neurosurgery. 1996;38(3):425-
432, discussion 432-3.
14. Lawton MT. Seven Aneurysms: Tenets and Techniques for Clipping.
New York: Thieme Medical Publishers; 2010.
CHAPTER 17 Anterior Circulation Aneurysms 281.e1
15. Day AL. Aneurysms of the ophthalmic segment. A clinical and
anatomical analysis. J Neurosurg. 1990;72(5):677-691.
16. Hayreh SS, Dass R. The ophthalmic artery: I. Origin and intra-cranial
and intra-canalicular course. Br J Ophthalmol. 1962;46(2):65-98.
17. International Study of Unruptured Intracranial Aneurysms Investi-
gators. Unruptured intracranial aneurysms–risk of rupture and risks
of surgical intervention. N Engl J Med. 1998;339(24):1725-1733.
18. Randell T, Niemela M, Kytta J, et al. Principles of neuroanesthesia
in aneurysmal subarachnoid hemorrhage: The Helsinki experience.
Surg Neurol. 2006;66(4):382-388, discussion 388.
19. Balak N. The Sylvian fissure, cistern and arachnoid membrane. Br
J Neurosurg. 2014;28(1):98-106.
20. Rinne J, Hernesniemi J, Niskanen M, et al. Analysis of 561 patients
with 690 middle cerebral artery aneurysms: anatomic and clini-
cal features as correlated to management outcome. Neurosurgery.
1996;38(1):2-11.
21. Kageyama Y, Fukuda K, Kobayashi S, et al. Cerebral vein disor-
ders and postoperative brain damage associated with the pteri-
onal approach in aneurysm surgery. Neurol Med Chir (Tokyo).
1992;32(10):733-738.
22. Dean BL, Wallace RC, Zabramski JM, et al. Incidence of superficial
sylvian vein compromise and postoperative effects on CT imaging
after surgical clipping of middle cerebral artery aneurysms. AJNR
Am J Neuroradiol. 2005;26(8):2019-2026.
23. Woertgen C, Rothoerl RD, Albert R, et al. Effects of temporary
clipping during aneurysm surgery. Neurol Res. 2008;30(5):542-546.
24. Tzu S. Art of War: Pearson Education, Asia 2003.
25. Hardesty DA, Thind H, Zabramski JM, et al. Safety, efficacy, and
cost of intraoperative indocyanine green angiography compared to
intraoperative catheter angiography in cerebral aneurysm surgery. J
Clin Neurosci. 2014;21(8):1377-1382.
26. Gibo H, Carver CC, Rhoton AL Jr, et al. Microsurgical anatomy of
the middle cerebral artery. J Neurosurg. 1981;54(2):151-169.
27. Rhoton AL Jr, Perlmutter D. Microsurgical anatomy of anterior
communicating artery aneurysms. Neurol Res. 1980;2(3-4):217-251.
28. Tang G, Cawley CM, Dion JE, et al. Intraoperative angiography
during aneurysm surgery: a prospective evaluation of efficacy. J
Neurosurg. 2002;96(6):993-999.