When Microsurgery Becomes the Only Lifesaving Resource: An Institutional Experience Treating Patients from Low-Income Backgrounds Affected by Posterior Circulation Brain Aneurysms

When Microsurgery Becomes the Only Lifesaving Resource: An Institutional Experience Treating Patients from Low-Income Backgrounds Affected by Posterior Circulation Brain Aneurysms | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article When Microsurgery Becomes the Only Lifesaving Resource: An Institutional Experience Treating Patients from Low-Income Backgrounds Affected by Posterior Circulation Brain Aneurysms José Luis Acha Sánchez, Luis Contreras Montenegro, Jhon E. Bocanegra-Becerra, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3922549/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Aug, 2024 Read the published version in Journal of Clinical Neuroscience → Version 1 posted You are reading this latest preprint version Abstract Background and objective Aneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern area of sophisticated technological advancements, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of considering the clinical setting in the treatment decision algorithm. Methods The authors conducted a retrospective review of the health records of patients receiving microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed. Results Surgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (62%), followed by the PCA (23%) and PICA (15%). Among neurological complications, 25% of patients developed paresis of the oculomotor nerve. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale score of 0–2). Conclusion The present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not yet available. Importantly, this clinical setting pressure can provide an imperative need to strive for microsurgical mastery and an opportunity for neurosurgeons in training to gain a competitive advantage. Neurosurgery Brain aneurysms Basilar artery Microsurgery Posterior cerebral artery Posterior inferior cerebellar artery Global Neurosurgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Aneurysms of the posterior circulation represent about 15–20% of intracranial aneurysms. 1 Given that the affected vessels are located in narrow corridors, possess complex surrounding anatomy, and provide vital irrigation, their associated morbidity and mortality are usually high. Furthermore, their natural history is generally poorer than aneurysms in the anterior circulation, with an estimated annual rupture risk of 3–5%. 2–6 Decision-making for aneurysms of the posterior circulation is often challenging. Several factors must be considered when choosing the optimal treatment, such as the patient´s comorbidities, aneurysm architecture, natural history, procedural safety, and the clinical setting. Treatment algorithms have evolved towards a patient-centered approach owing to the distinct advantages of both treatment approaches; 7 for example, endovascular therapy can provide a greater free-of-disability survival, 8,9 whereas microsurgery has been associated with lower rebleeding rates and higher aneurysm occlusion rates. 9,10 In addition, there has been a trend toward favoring endovascular treatment over microsurgery for aneurysms of the posterior circulation, as illustrated in landmark trials such as the International Study of Unruptured Intracranial Aneurysms (ISUA) and the International Subarachnoid Aneurysm (ISAT). 11,12 However, despite the increasing reliance on endovascular procedures, their limited availability in low-to-middle-income countries may represent a barrier to optimizing patients’ treatment. 13–15 In the modern area, microsurgery can remain the treatment of choice in settings with limited availability of endovascular devices. Our institution, “Hospital Nacional Dos de Mayo,” located in Lima, Peru, is an important referral center within the Ministry of Health network, offering highly complex microsurgical treatment to patients of low-income backgrounds nationwide. Herein, by presenting our single-center experience, we aim to illustrate microsurgery's crucial and manifest role in this scenario. Methods This study was approved by the Institutional Review Board (IRB) of the “Hospital Nacional Dos de Mayo” in Lima, Peru. Clinical records were retrospectively reviewed to search for patients with posterior circulation aneurysms who underwent microsurgical management between 2018 and 2022. Variables of interest were collected in a standardized Microsoft Excel® sheet containing relevant data such as age, sex, clinical presentation, comorbidities, Hunt and Hess grading scale (H&H), Fisher grading scale, aneurysms features (i.e., morphology, size, location, multiplicity), surgical approach undertaken, postoperative complications, clinical follow-up evaluated with the modified Rankin scale at patient´s discharge and at one, three- and six-months post-surgery. Descriptive analysis was performed using IBM® SPSS® software (version 29). Categorical and continuous data were summarized as proportions and measures of central tendency, respectively. The final data report was processed according to the STROBE Statement. Results Patients´ clinical information A total of 12 patients (75% female) with a mean age of 52.4 years (range: 43–63) received microsurgical treatment for intracranial aneurysms located in the posterior cerebral circulation. At clinical presentation, headache was the prevalent symptom (92%), followed by alteration in the level of consciousness (58%) and nausea and vomiting (50%). Among medical comorbidities, patients had hypertension (67%), diabetes mellitus (8%), and obesity (17%). About 33% of patients presented with a poor H&H grading score of III-V (median: II) and a median Fisher grading score of 3 (IQR 1–4). Detailed information on the patient´s demographics and clinical features is shown in Table 1 . A total of 15 aneurysms were described, including 13 in the posterior circulation coexisting with 2 in the anterior circulation. All aneurysms were of saccular morphology; 62% were unruptured, and 25% were multiple. The median size was 7.9 mm ± 5.3 (5.6–13.6 mm). The predominant location was the basilar artery (62%), followed by the posterior inferior cerebellar artery (15%) and the posterior cerebral artery at the P1 (15%) and P1-P2 segments (8%) (Table 2 ). Table 1 Patient demographics and clinical information at presentation. 1 mean ± SD (range); 2 median (interquartile range, IQR). Variable n (%) Patients Female Male 12 9 (75%) 3 (25%) Age (years) 52.4 ± 7.5 (43–63) 1 Clinical Presentation Headache 11(91.7%) Nausea and vomiting 6 (50%) Alteration of the level of consciousness 7 (58.3%) Coma 1 (8.3%) Medical comorbidities Hypertension 8 (66.7%) Diabetes mellitus 1 (8.3%) Obesity 2 (16.7%) Hunt and Hess Grading Scale I2 (1–4) 2 I 4 (33.3%) II 3 (25%) III 0 (0%) IV 4 (33.3%) V 0 (0%) Modified Fisher Grading scale 3 (1–4) 2 1 0 (0%) 2 0 (0%) 3 4 (33.3%) 4 7 (58.3%) Table 2 Aneurysms’ Characteristics. 1 mean ± SD (range). Variable n (%) Rupture status at presentation 13 Ruptured 8 (61.5%) Unruptured 5 (38.5%) Multiplicity 2 (15.4%) Morphology Sacular 13 (100%) Size (mm) 6.2 ± 0.6 (5.6–13.6) 1 < 7 5 (38.5%) 7–12 3 (23.1%) 13–24 5 (38.5%) Location Basilar artery 8 (61.5%) Posterior cerebral artery P1 segment 2 (15.4%) P2 segment 1 (7.7%) Posterior inferior cerebellar artery 2 (15.4%) Surgical details A pterional craniotomy (75%) was the predominant approach, followed by a suboccipital craniotomy (17%) and decompressive craniectomy (8%). To corroborate vascular supply in the adjacent aneurysm territory and perforators, intraoperative video angiography with fluorescein (infusion rate: 125mg/2.5cc) was utilized post-clipping of aneurysms. Among intraoperative complications, 17% of patients experienced aneurysm rupture, which was promptly controlled. Postoperative complications included hydrocephalus (17%), cerebral infarction (25%), infection (8%), and cerebrospinal fluid fistula (8%). Two patients died because of cerebral vasospasm, cerebral infarction, and intracranial hypertension (Table 3 ). Table 3 Surgical Techniques, outcomes, and follow-up. mRS = modified Rankin Scale score. 1 mean ± SD (range). Variable n (%) Surgical approach Pterional 9 (75%) Suboccipital 2 (16.7%) Craniectomía descompresiva 1 (8.3%) Surgical details Clipping 13 (100%) Intraoperative visualization tools Videoangiography with fluorescein 13 (100%) Endoscopy 2 (16.7%) Operative time (hours) 4.10 ± 1,82 (1,5–10,8) 1 Intraoperative aneurysm rupture 2 (16.7%) Postoperative complications Rebleeding 0 (0%) Cerebral infarction 3 (25%) Hydrocephalus 2 (16.7%) Infection 1 (8.3%) Cerebrospinal fluid fistula 1 (8.3%) Aneurysm Obliteration Complete 13 (100%) Partial 0 (0%) Clinical outcome at hospital discharge • Good (mRS 0–2) 8 (66.7%) • Poor (mRS 3–5) 2 (16.7%) • Death (mRS 6) 2 (16.7%) Aneurysm recurrence at 6-month follow-up 0 Clinical outcomes and Follow-up At hospital discharge, most patients had a mRS 0–2 (66.7%), followed by a mRS 3–5 (16.7%) and mRS 6 (16.7%). At the six-month follow-up, 90% of patients had a mRS 0–2 and 10% had a mRS 3–5 (Table 4 ). Table 4 Patients’ details regarding approaches utilized, postoperative complications, and neurological outcomes. CI: cerebral infarction, F: female; M: male mRS: modified Rankin scale; IH: Intracranial hypertension; Ptnl: pterional; SO: suboccipital N Age (years) Sex Surgical approach Postoperative complications mRS at discharge mRS at 6 months 1 58 M Decompressive craniotomy CI and IH 6 - 2 63 F SO None 1 0 3 43 F Ptnl None 1 0 4 46 F Ptnl None 1 0 5 41 F Ptnl Hydrocephalus 4 4 6 55 M Ptnl None 1 0 7 58 F Ptnl CI and IH 6 - 8 68 F SO None 1 0 9 54 F Ptnl Hydrocephalus 1 0 10 46 F Ptnl CI 1 0 11 44 F Ptnl None 1 0 12 56 M Ptnl None 4 2 Illustrative cases Microsurgical management of aneurysms was evaluated based on the patient´s clinical history and aneurysm features such as rupture status, multiplicity, large size, presence of a wide neck, and progressive neurological deterioration as suggestive of increasing mass effect. Case 1 A 44-year-old female presented with a sudden headache and vomiting. Upon clinical examination and brain imaging, the patient had a Glasgow Coma Scale (GCS) score of 15, a H&H score of I, and a World Federation of Neurosurgical Societies (WFNS) score of I. A cerebral angiotomography showed a ruptured saccular aneurysm in the P1-P2 segment of the PCA (Fig. 1 ). The patient underwent a right frontal-temporal-zygomatic craniotomy with a broad dissection of the Sylvian fissure. Access to the carotid-oculomotor cistern was enabled, followed by gentle dissection of the Liliquiest’s membrane. We performed proximal temporal control of the basilar artery and aneurysm neck clipping within the posterior fossa. Finally, fluorescein angiography and endoscopy corroborated vascular permeability in collateral and perforators (Fig. 1 ). On follow-up, the patient had right oculomotor nerve paresis with a mRS of 1 at hospital discharge. A 3-month follow-up demonstrated improvement in the oculomotor nerve function. A 6-month follow-up showed the patient had full neurological recovery (mRS: 0). Case II A 58-year-old male presented with a sudden headache, alteration in the level of consciousness, and vomiting. His medical history was remarkable for uncontrolled hypertension. Upon examination, he had a GCS of 8, 3/5 quadriparesis, H&H score of IV, and WFNS of IV, which prompted neurointensive care. Brain imaging suggested the presence of SAH Fisher grade IV with a frontoparietal hematoma and intraventricular hemorrhage. Besides, it depicted a 12x7mm distal fusiform aneurysm in an accessory A2 branch stemming from the anterior communicating complex and a 3.3x3.8mm saccular aneurysm in the distal portion of the basilar artery (Fig. 2 ). The patient underwent a pterional craniotomy with ample exposure to the temporal bone base. After carefully dissecting the Sylvian fissure and gaining exposure to the anterior communicating complex, clipping of the accessory A2 branch was performed proximally. Subsequently, after gentle dissection of the Liliquiest´s membrane and access to the posterior fossa, we clipped the distal basilar aneurysm neck. In both surgical stages, fluorescein video angiography confirmed the patency of the permeability of the adjacent vascular supply (Fig. 3 ). On follow-up, the patient was discharged with a GSC of 13, 4/5 quadriparesis, and right oculomotor paresis. At 6-month follow-up, the patient had a mRS of 2 and complete recovery of the oculomotor nerve paresis. Case III A 75-year-old female presented with a sudden headache and loss of consciousness. On examination, the patient had H&H of I. Brain imaging showed intraventricular hemorrhage, hydrocephalus, and a ruptured saccular basilar apex aneurysm (Fig. 4 ). The patient underwent a right personal approach with extradural anterior clinoidectomy and dissection of the distal dural ring. After recognition of the vascular lesion and identification of the aneurysms, a permanent clip was applied (Fig. 5 ). On follow-up, the patient had a favorable clinical evolution with a mRS of 2 at six months. Discussion Posterior circulation aneurysms constitute about 3.8–15% of intracranial aneurysms and carry a higher risk of rupture than those located in the anterior circulation. 3,4,11,16–18 Notably, given their anatomical location, proximity to vital structures, reduced space in the cranial fossa, and mass effect, they can be associated with poorer clinical outcomes. 5 Furthermore, rupture risk can be increased depending on the patient´s ethnicity. For instance, in the Japanese population, the rupture risk can be 2.5 times greater than in the general population. 19 The risk can also be higher depending on the aneurysm location. A study showed that among unruptured aneurysms, those in the basilar apex and superior cerebellar artery had an annual rupture rate of 6.9%. 20 Treatment strategies include microsurgical and endovascular techniques. The latter has been increasingly adopted because of its minimally invasive approach. 21,22 However, in aneurysms with wide neck, thrombosed, giant-sized, involving perforators and branches, endovascular treatment can be limited to provide complete aneurysm occlusion with greater recurrence and rebleeding rates. 9,10,23,24 Furthermore, the need for antiaggregating therapy can be associated with bleeding. 25 On the other hand, microsurgical management can be beneficial for select cases with a greater occlusion rate, less likelihood of recurrence, and lesser risk of rebleeding and hydrocephalus. 26,27 Tsianaka et al. performed a meta-analysis comparing endovascular coiling to microsurgical clipping of posterior circulation aneurysms. Statistical analysis yielded significantly better outcomes regarding permanent neurological deficit when treated with coiling, but clipping was associated with better outcomes concerning reintervention. 28 Therefore, there is no conclusive answer to which is the overall better option for every patient. Current literature presents heterogeneity in terms of sample sizes, baseline characteristics of the patients (presentation, age, sex, comorbidities, ethnicity, etc), and neurosurgeon skill. Future studies should aim to provide larger sample sizes, multivariate and subgroup analyses, and longer follow-up periods. Shifting to flow-diverters, they are currently gaining significant attention, but results for aneurysms of the posterior circulation are still not completely encouraging. 29–31 For complex aneurysms, when conventional strategies are unsuitable, considering the outcomes, open surgery revascularizations are an adequate option for skilled neurosurgeons, 32 mainly in limited-resource countries. 15 When comparing endovascular to surgical approaches for PICA aneurysms, Saal-Zapata et al. demonstrated that the literature, despite extensive, carries a serious risk of bias. Hence, the authors emphasize the case-by-case and institutional experience value when choosing the preferable treatment option. 33 Moreover, another systematic review and meta-analysis comparing treatments for PICA saccular aneurysms conducted by Ali et al. showcased microsurgical clipping resulting in superior angiographic outcomes and similar functional outcomes but higher rates of lower cranial nerve palsy compared with EVT. 34 The authors acknowledge the results of this study are limited by its retrospective and observational nature and the small sample size of patients. Nevertheless, the relevant insights from this institutional experience are worth highlighting. While endovascular treatment has emerged as an innovative approach for posterior circulation aneurysms, consideration of the clinical setting is an essential factor within the decision-making process in low-to-middle-income countries. Consequently, microsurgery has a remarkable and manifest role in such settings as the only treatment of choice. While this may bring controversy to providing optimal treatment, the associated setting pressure can represent an opportunity for neurosurgeons to strive for microsurgical mastery and gain a competitive advantage. 35 Conclusion In the modern era of the treatment of posterior circulation aneurysms, endovascular techniques have shown favorable outcomes compared with microsurgery for select cases. However, amid the limited availability of endovascular devices in low-to-middle-income countries, microsurgery remains the treatment of choice. The present case series illustrates optimal microsurgical management of patients from low-income backgrounds affected by posterior circulation brain aneurysms. Notably, the manifest role of microsurgery inherently exhorts neurosurgeons in training to achieve a high level of microsurgical mastery to provide safe patient treatment. Declarations Conflicts of Interest: The authors declare no competing interest. Funding: No funding was provided for this study. Note: Figures 2A,2B, 2D, and 2E are licensed under theCreative Commons CC BY, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A link to the recently published article is provided: https://academic.oup.com/jscr/article/2024/1/rjad742/7560344 References Sharma D, Singh D, Jagetia A, Singh H, Tandon M, Ganjoo P. Intra procedure rupture of intracranial aneurysm during endovascular coiling: Neurosurgeons experience and review of the literature. Neurol INDIA . 2011;59(5):42-47. doi:10.4103/0028-3886.86542 Etminan N, Brown RD, Beseoglu K, et al. The unruptured intracranial aneurysm treatment score. Neurology . 2015;85(10):881-889. doi:10.1212/WNL.0000000000001891 Greving JP, Wermer MJH, Brown RD, et al. Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. Lancet Neurol . 2014;13(1):59-66. doi:10.1016/S1474-4422(13)70263-1 Molyneux AJ, Kerr RSC, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet Lond Engl . 2005;366(9488):809-817. doi:10.1016/S0140-6736(05)67214-5 Williamson RW, Wilson DA, Abla AA, et al. Clinical characteristics and long-term outcomes in patients with ruptured posterior inferior cerebellar artery aneurysms: a comparative analysis. J Neurosurg . 2015;123(2):441-445. doi:10.3171/2014.10.JNS141079 Bijlenga P, Ebeling C, Jaegersberg M, et al. Risk of rupture of small anterior communicating artery aneurysms is similar to posterior circulation aneurysms. Stroke . 2013;44(11):3018-3026. doi:10.1161/STROKEAHA.113.001667 Waqas M, Monteiro A, Cappuzzo JM, Tutino VM, Levy EI. Evolution of the patient-first approach: a dual-trained, single-neurosurgeon experience with 2002 consecutive intracranial aneurysm treatments. J Neurosurg . 2022;137(6):1751-1757. doi:10.3171/2022.2.JNS22105 Molyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet Lond Engl . 2002;360(9342):1267-1274. doi:10.1016/s0140-6736(02)11314-6 Molyneux AJ, Birks J, Clarke A, Sneade M, Kerr RSC. The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). Lancet Lond Engl . 2015;385(9969):691-697. doi:10.1016/S0140-6736(14)60975-2 Spetzler RF, McDougall CG, Albuquerque FC, et al. The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg . 2013;119(1):146-157. doi:10.3171/2013.3.JNS12683 Wiebers DO, Whisnant JP, Huston J, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet Lond Engl . 2003;362(9378):103-110. doi:10.1016/s0140-6736(03)13860-3 Bender MT, Wendt H, Monarch T, et al. Shifting Treatment Paradigms for Ruptured Aneurysms from Open Surgery to Endovascular Therapy Over 25 Years. World Neurosurg . 2017;106:919-924. doi:10.1016/j.wneu.2017.07.074 Ferreira T, Awuah WA, Tan JK, et al. The current landscape of intracranial aneurysms in Africa: management outcomes, challenges, and strategies-a narrative review. Neurosurg Rev . 2023;46(1):194. doi:10.1007/s10143-023-02102-4 Gonçalves B, Rynkowski C, Turon R, et al. Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country. Neurocrit Care . 2023;38(2):378-387. doi:10.1007/s12028-022-01629-6 Labib MA, Rumalla K, Karahalios K, et al. Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis. Neurosurgery . 2022;91(3):470-476. doi:10.1227/neu.0000000000002061 Eller JL, Dumont TM, Mokin M, et al. Endovascular treatment of posterior circulation aneurysms. Neurol Res . 2014;36(4):339-343. doi:10.1179/1743132814Y.0000000323 Brown RD, Broderick JP. Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. Lancet Neurol . 2014;13(4):393-404. doi:10.1016/S1474-4422(14)70015-8 Sonobe M, Yamazaki T, Yonekura M, Kikuchi H. Small unruptured intracranial aneurysm verification study: SUAVe study, Japan. Stroke . 2010;41(9):1969-1977. doi:10.1161/STROKEAHA.110.585059 de Rooij NK, Linn FHH, van der Plas JA, Algra A, Rinkel GJE. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry . 2007;78(12):1365-1372. doi:10.1136/jnnp.2007.117655 UCAS Japan Investigators, Morita A, Kirino T, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med . 2012;366(26):2474-2482. doi:10.1056/NEJMoa1113260 Hua X, Gray A, Wolstenholme J, et al. Survival, Dependency, and Health-Related Quality of Life in Patients With Ruptured Intracranial Aneurysm: 10-Year Follow-up of the United Kingdom Cohort of the International Subarachnoid Aneurysm Trial. Neurosurgery . 2021;88(2):252-260. doi:10.1093/neuros/nyaa454 Spetzler RF, McDougall CG, Zabramski JM, et al. Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg . 2019;132(3):771-776. doi:10.3171/2018.8.JNS181846 Mascitelli JR, Lawton MT, Hendricks BK, Nakaji P, Zabramski JM, Spetzler RF. Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial. Neurosurgery . 2019;85(5):622-631. doi:10.1093/neuros/nyy439 Shi X, Qian H, Singh KCKI, et al. Surgical management of vertebral and basilar artery aneurysms: a single center experience in 41 patients. Acta Neurochir (Wien) . 2013;155(6):1087-1093. doi:10.1007/s00701-013-1656-6 Gross BA, Frerichs KU. Stent usage in the treatment of intracranial aneurysms: past, present and future. J Neurol Neurosurg Psychiatry . 2013;84(3):244-253. doi:10.1136/jnnp-2011-302007 Li H, Pan R, Wang H, et al. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. Stroke . 2013;44(1):29-37. doi:10.1161/STROKEAHA.112.663559 Jiang Z, Chen Y, Zeng C, Feng J, Wan Y, Zhang X. Neurosurgical Clipping versus Endovascular Coiling for Patients with Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg . 2020;138:e191-e222. doi:10.1016/j.wneu.2020.02.091 Tsianaka E, Al-Shawish A, Potapov A, Fountas K, Spyrou M, Konovalov N. Clipping versus coiling in posterior circulation intracranial aneurysms: a meta-analysis. Chin Neurosurg J . 2019;5:16. doi:10.1186/s41016-019-0163-x Kiyofuji S, Graffeo CS, Perry A, et al. Meta-analysis of treatment outcomes of posterior circulation non-saccular aneurysms by flow diverters. J Neurointerventional Surg . 2018;10(5):493-499. doi:10.1136/neurintsurg-2017-013312 Wang CB, Shi WW, Zhang GX, Lu HC, Ma J. Flow diverter treatment of posterior circulation aneurysms. A meta-analysis. Neuroradiology . 2016;58(4):391-400. doi:10.1007/s00234-016-1649-2 Abdel-Tawab M, Abdeltawab AK, Abdelmonem M, et al. Efficacy and safety of flow diverters in posterior circulation aneurysms and comparison with their efficacy in anterior circulation aneurysms: A systematic review and meta-analysis. Interv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci . 2021;27(5):609-621. doi:10.1177/15910199211003017 Oliveira L de B, Sousa MP, Ribas LRC, et al. Efficacy and Safety of Extracranial-Intracranial Bypass Surgery for Posterior Circulation Aneurysms: A Systematic Review and Single-Arm Meta-Analysis. World Neurosurg . 2023;183:15-28. doi:10.1016/j.wneu.2023.12.002 Saal-Zapata G, Rodriguez-Calienes A, Malaga M, et al. Microsurgical and endovascular treatment of posterior inferior cerebellar artery aneurysms: a systematic review and meta-analysis. J Neurosurg Sci . 2023;67(5):638-652. doi:10.23736/S0390-5616.22.05710-1 Ali AMS, Hannan CJ, Islim AI, Mascitelli JR, Javadpour M. Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysms: Systematic Review and Meta-Analysis. World Neurosurg . 2022;162:e168-e177. doi:10.1016/j.wneu.2022.02.103 Abecassis IJ, Sen RD, Ellenbogen RG, Sekhar LN. Developing microsurgical milestones for psychomotor skills in neurological surgery residents as an adjunct to operative training: the home microsurgery laboratory. J Neurosurg . 2020;135(1):194-204. doi:10.3171/2020.5.JNS201590 Tables Table 1. Patient demographics and clinical information at presentation. 1 mean ± SD (range); 2 median (interquartile range, IQR). Variable n (%) Patients Female Male 12 9 (75%) 3 (25%) Age (years) 52.4 ± 7.5 (43-63) 1 Clinical Presentation Headache 11(91.7%) Nausea and vomiting 6 (50%) Alteration of the level of consciousness 7 (58.3%) Coma 1 (8.3%) Medical comorbidities Hypertension 8 (66.7%) Diabetes mellitus 1 (8.3%) Obesity 2 (16.7%) Hunt and Hess Grading Scale I2 (1-4) 2 I 4 (33.3%) II 3 (25%) III 0 (0%) IV 4 (33.3%) V 0 (0%) Modified Fisher Grading scale 3 (1–4) 2 1 0 (0%) 2 0 (0%) 3 4 (33.3%) 4 7 (58.3%) Table 2. Aneurysms’ Characteristics. 1 mean ± SD (range). Variable n (%) Rupture status at presentation 13 Ruptured 8 (61.5%) Unruptured 5 (38.5%) Multiplicity 2 (15.4%) Morphology Sacular 13 (100%) Size (mm) 6.2 ± 0.6 (5.6-13.6) 1 <7 5 (38.5%) 7–12 3 (23.1%) 13–24 5 (38.5%) Location Basilar artery 8 (61.5%) Posterior cerebral artery P1 segment 2 (15.4%) P2 segment 1 (7.7%) Posterior inferior cerebellar artery 2 (15.4%) Table 3. Surgical Techniques, outcomes, and follow-up. mRS = modified Rankin Scale score. 1 mean ± SD (range). Variable n (%) Surgical approach Pterional 9 (75%) Suboccipital 2 (16.7%) Craniectomía descompresiva 1 (8.3%) Surgical details Clipping 13 (100%) Intraoperative visualization tools Videoangiography with fluorescein 13 (100%) Endoscopy 2 (16.7%) Operative time (hours) 4.10 ± 1,82 (1,5–10,8) 1 Intraoperative aneurysm rupture 2 (16.7%) Postoperative complications Rebleeding 0 (0%) Cerebral infarction 3 (25%) Hydrocephalus 2 (16.7%) Infection 1 (8.3%) Cerebrospinal fluid fistula 1 (8.3%) Aneurysm Obliteration Complete 13 (100%) Partial 0 (0%) Clinical outcome at hospital discharge Good (mRS 0–2) 8 (66.7%) Poor (mRS 3–5) 2 (16.7%) Death (mRS 6) 2 (16.7%) Aneurysm recurrence at 6-month follow-up 0 Table 4. Patients’ details regarding approaches utilized, postoperative complications, and neurological outcomes. CI: cerebral infarction, F: female; M: male mRS: modified Rankin scale; IH: Intracranial hypertension; Ptnl: pterional; SO: suboccipital N Age (years) Sex Surgical approach Postoperative complications mRS at discharge mRS at 6 months 1 58 M Decompressive craniotomy CI and IH 6 - 2 63 F SO None 1 0 3 43 F Ptnl None 1 0 4 46 F Ptnl None 1 0 5 41 F Ptnl Hydrocephalus 4 4 6 55 M Ptnl None 1 0 7 58 F Ptnl CI and IH 6 - 8 68 F SO None 1 0 9 54 F Ptnl Hydrocephalus 1 0 10 46 F Ptnl CI 1 0 11 44 F Ptnl None 1 0 12 56 M Ptnl None 4 2 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Published Journal Publication published 01 Aug, 2024 Read the published version in Journal of Clinical Neuroscience → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3922549","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":270755321,"identity":"de202fae-0155-4325-ae11-492f1c117b36","order_by":0,"name":"José Luis Acha Sánchez","email":"","orcid":"https://orcid.org/0000-0002-8427-2390","institution":"Vascular Neurosurgery and Skull Base Division, Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"Luis Acha","lastName":"Sánchez","suffix":""},{"id":270755322,"identity":"6cacd3be-c004-41d1-bdee-f83cc527ea77","order_by":1,"name":"Luis Contreras Montenegro","email":"","orcid":"","institution":"Vascular Neurosurgery and Skull Base Division, Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru","correspondingAuthor":false,"prefix":"","firstName":"Luis","middleName":"Contreras","lastName":"Montenegro","suffix":""},{"id":270755323,"identity":"d28b8797-13b2-4d77-9305-37ebdcb90b61","order_by":2,"name":"Jhon E. Bocanegra-Becerra","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACxhkgogEhkMAPJJhJ0yLZQEALgwS6FoMDBLQwz24+9oBxh408/+zmw68rahjyjG/kHvxcwHBHDqfD5hxLN2A8k2Y4486xNMszxxiKzW7kJUvPYHhmjNsvOWYSjG2HExhu5JgZNrAxJG4DMph5GA4nNhDSIn8j/5thwz+GxM0zIFrqCWoxuJHD/LCxjSFxgwRESwJuh6WlSSQC/bLxRpoZY2OfRLHEmXfJ0jwGzwxx2WI4I/mYxEdgiMndSH78seGbTR5/OzDEeCruyOOyBWwW1A1sEpBo4gFiUOzgAMhmMX+A0CAtDLi1jIJRMApGwYgDAJefWOy20eHoAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-3661-7195","institution":"Cayetano Heredia Peruvian University","correspondingAuthor":true,"prefix":"","firstName":"Jhon","middleName":"E.","lastName":"Bocanegra-Becerra","suffix":""},{"id":270755324,"identity":"1624a458-864b-4812-a503-8748285c5501","order_by":3,"name":"Manuel Cueva","email":"","orcid":"","institution":"Vascular Neurosurgery and Skull Base Division, Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru","correspondingAuthor":false,"prefix":"","firstName":"Manuel","middleName":"","lastName":"Cueva","suffix":""},{"id":270755325,"identity":"017e6fa6-c6a1-45b3-8544-e8f24ab39d95","order_by":4,"name":"Adriana Bellido","email":"","orcid":"","institution":"Vascular Neurosurgery and Skull Base Division, Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru","correspondingAuthor":false,"prefix":"","firstName":"Adriana","middleName":"","lastName":"Bellido","suffix":""},{"id":270755326,"identity":"523717a2-06bb-47ec-a72b-2143f0f77413","order_by":5,"name":"Shamir Contreras","email":"","orcid":"","institution":"Vascular Neurosurgery and Skull Base Division, Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru","correspondingAuthor":false,"prefix":"","firstName":"Shamir","middleName":"","lastName":"Contreras","suffix":""},{"id":270755327,"identity":"4b350f5d-098e-43e4-8c8a-8f372381e3d8","order_by":6,"name":"Oscar Santos","email":"","orcid":"","institution":"Vascular Neurosurgery and Skull Base Division, Department of Neurosurgery, Hospital Nacional Dos de Mayo, Lima, Peru","correspondingAuthor":false,"prefix":"","firstName":"Oscar","middleName":"","lastName":"Santos","suffix":""},{"id":270755328,"identity":"8ccc75f1-d4a3-4219-bcd5-7a91584e367b","order_by":7,"name":"Leonardo de Barros Oliveira","email":"","orcid":"","institution":"Faculty of Medicine, State University of Ponta Grossa, Paraná, Brazil","correspondingAuthor":false,"prefix":"","firstName":"Leonardo","middleName":"de Barros","lastName":"Oliveira","suffix":""},{"id":270755329,"identity":"8ca7569c-41c0-47ec-9c61-be31f17b2a2e","order_by":8,"name":"Sávio Batista","email":"","orcid":"","institution":"Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil","correspondingAuthor":false,"prefix":"","firstName":"Sávio","middleName":"","lastName":"Batista","suffix":""},{"id":270755330,"identity":"555b6d14-e2ba-4369-97ab-3972e6ba98a6","order_by":9,"name":"Jhair Alejandro Colán","email":"","orcid":"","institution":"School of Medicine, University of Pittsburgh, PA, USA","correspondingAuthor":false,"prefix":"","firstName":"Jhair","middleName":"Alejandro","lastName":"Colán","suffix":""}],"badges":[],"createdAt":"2024-02-03 02:05:26","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3922549/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3922549/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1016/j.jocn.2024.06.014","type":"published","date":"2024-08-01T18:47:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":50749251,"identity":"30875362-2e50-4faf-b041-7d2c45db56cc","added_by":"auto","created_at":"2024-02-06 17:23:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1417928,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBrain Imaging and Intraoperative course from Case I.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA-B. Three-dimensional CTA showed an aneurysm at the P1-PCom junction (red arrow); C-D. Digital subtraction angiography revealed an aneurysm of the right P1/P2 segment; E. Access to the carotid-oculomotor corridor of the posterior circulation; F. clipping of the aneurysmal neck; G-H. Aneurysm sac exclusion and patency are corroborated by fluorescein angiography and endoscopic assisted visualization confirmed patent branches next to the clips. PCom: posterior communicating. CTA: computed tomography angiography\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3922549/v1/8c2e306f8915c477c8c89ab8.png"},{"id":50749247,"identity":"5c664f59-ddd9-42b9-a090-dde32ede3565","added_by":"auto","created_at":"2024-02-06 17:23:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2139793,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBrain Imaging from Case II. \u003c/strong\u003eA-B. Angiotomography showed a fusiform vascular dilation (yellow circle) and a saccular aneurysm of the basilar artery (green arrow); C. Lateral view of a three-dimensional reconstruction image revealed an accessory A2 artery (green line) with a 12x7mm aneurysm in its distal portion; D. Accessory A2 artery and 3.3x3.8 mm saccular basilar aneurysm (green arrows); E-F. Post-operative tomography demonstrated clear improvement of hematoma, clipping of accessory A2 artery (red arrow), and aneurysms´ exclusion from circulation (yellow arrow).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3922549/v1/381481b208b40d416b2c2360.png"},{"id":50749249,"identity":"579a8be3-8e2a-4b29-89f1-b2e814503af8","added_by":"auto","created_at":"2024-02-06 17:23:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1679715,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoperative images from case II.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Anatomy of the anterior communicating complex depicts the A1 and A2 segments of the right and left anterior cerebral artery, ACoA, and an accessory A2 artery (red arrows); B-C. Clipping and closure of accessory A2 at its proximal segment and the adjacent patency are corroborated with fluorescein video angiography; D. Approach through the oculomotor carotid triangle allowed dissection of Liliequist´s membrane (yellow arrow); E-F. Images show clipping of the basilar aneurysm neck (blue arrow) and the patency of adjacent vessels by fluorescein angiography. ACoA: Anterior Communicating Artery.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3922549/v1/40bc2ad0bf3e53a71832b8e1.png"},{"id":50749248,"identity":"52bef98b-76f2-4c17-8db4-0ca59ed3f582","added_by":"auto","created_at":"2024-02-06 17:23:39","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2182530,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBrain Imaging and Angiography from Case III.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Superior view of the interpeduncular aneurysm sac; B. Superior-posterior view of the aneurysm sac showed the zone of rupture (red arrow); C. Three-dimensional image reconstruction depicted an aneurysm of 6.31 x 8.71 mm (green arrow); D. Carotid – oculomotor triangle (red color) corridor that communicates with the posterior fossa, P1-P1 and bilateral SCAs (green arrows); E-F. Posterior and lateral view of digital subtraction angiography shows the aneurysmal sac with a rupture zone (red arrow); both P1 and bilateral SCAs are observed. SCA: Superior cerebellar artery\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-3922549/v1/d3575febeef10005a78858ea.png"},{"id":50749250,"identity":"2c88da59-72f0-4d23-8f00-114d292a1b4a","added_by":"auto","created_at":"2024-02-06 17:23:39","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2441795,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMicrosurgical anatomy from Case III\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eA. Carotid cistern opening and ICA dissection; B. Subarachnoid space dissection at the Sylvian fissure; C. Colored triangles that allowed access to the basilar artery are shown: optico-carotid (yellow), carotid-oculomotor (green), and supra-carotid bifurcation (red); D. Carotid-oculomotor triangle and dissection of Liliequist's membrane (blue arrow); E. The Pcom artery, P1 segment of the PCA, cranial nerve III, and the free edge of the tentorium are depicted; F. Basilar apex aneurysm, P1 segments, and right SCA; G. Right P1 and aneurysm visualization; H. Proximal and distal neck of the aneurysm (blue arrow); I. Temporary clipping of the basilar artery and neck dissection; J-K. Clipping and exclusion of the aneurysm sac; L. Fluorescein video angiography corroborated the exclusion of the aneurysm sac (blue arrow). ICA: internal carotid artery. Pcom: posterior communicating artery. PCA: posterior cerebral artery. SCA: superior cerebellar artery.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-3922549/v1/0795b526eadae6c3fccaad36.png"},{"id":60099799,"identity":"c6b3e121-ffa0-4031-8f0b-3bfe2ab983f5","added_by":"auto","created_at":"2024-07-11 18:48:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":19294308,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3922549/v1/bdc8b4e6-40c7-4de9-902f-ee2bd3a080e8.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eWhen Microsurgery Becomes the Only Lifesaving Resource: An Institutional Experience Treating Patients from Low-Income Backgrounds Affected by Posterior Circulation Brain Aneurysms\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAneurysms of the posterior circulation represent about 15\u0026ndash;20% of intracranial aneurysms.\u003csup\u003e1\u003c/sup\u003e Given that the affected vessels are located in narrow corridors, possess complex surrounding anatomy, and provide vital irrigation, their associated morbidity and mortality are usually high. Furthermore, their natural history is generally poorer than aneurysms in the anterior circulation, with an estimated annual rupture risk of 3\u0026ndash;5%.\u003csup\u003e2\u0026ndash;6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDecision-making for aneurysms of the posterior circulation is often challenging. Several factors must be considered when choosing the optimal treatment, such as the patient\u0026acute;s comorbidities, aneurysm architecture, natural history, procedural safety, and the clinical setting. Treatment algorithms have evolved towards a patient-centered approach owing to the distinct advantages of both treatment approaches;\u003csup\u003e7\u003c/sup\u003e for example, endovascular therapy can provide a greater free-of-disability survival,\u003csup\u003e8,9\u003c/sup\u003e whereas microsurgery has been associated with lower rebleeding rates and higher aneurysm occlusion rates.\u003csup\u003e9,10\u003c/sup\u003e In addition, there has been a trend toward favoring endovascular treatment over microsurgery for aneurysms of the posterior circulation, as illustrated in landmark trials such as the International Study of Unruptured Intracranial Aneurysms (ISUA) and the International Subarachnoid Aneurysm (ISAT).\u003csup\u003e11,12\u003c/sup\u003e However, despite the increasing reliance on endovascular procedures, their limited availability in low-to-middle-income countries may represent a barrier to optimizing patients\u0026rsquo; treatment.\u003csup\u003e13\u0026ndash;15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the modern area, microsurgery can remain the treatment of choice in settings with limited availability of endovascular devices. Our institution, \u0026ldquo;Hospital Nacional Dos de Mayo,\u0026rdquo; located in Lima, Peru, is an important referral center within the Ministry of Health network, offering highly complex microsurgical treatment to patients of low-income backgrounds nationwide. Herein, by presenting our single-center experience, we aim to illustrate microsurgery's crucial and manifest role in this scenario.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was approved by the Institutional Review Board (IRB) of the \u0026ldquo;Hospital Nacional Dos de Mayo\u0026rdquo; in Lima, Peru. Clinical records were retrospectively reviewed to search for patients with posterior circulation aneurysms who underwent microsurgical management between 2018 and 2022. Variables of interest were collected in a standardized Microsoft Excel\u0026reg; sheet containing relevant data such as age, sex, clinical presentation, comorbidities, Hunt and Hess grading scale (H\u0026amp;H), Fisher grading scale, aneurysms features (i.e., morphology, size, location, multiplicity), surgical approach undertaken, postoperative complications, clinical follow-up evaluated with the modified Rankin scale at patient\u0026acute;s discharge and at one, three- and six-months post-surgery.\u003c/p\u003e \u003cp\u003eDescriptive analysis was performed using IBM\u0026reg; SPSS\u0026reg; software (version 29). Categorical and continuous data were summarized as proportions and measures of central tendency, respectively. The final data report was processed according to the STROBE Statement.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003ePatients\u0026acute; clinical information\u003c/h2\u003e\n \u003cp\u003eA total of 12 patients (75% female) with a mean age of 52.4 years (range: 43\u0026ndash;63) received microsurgical treatment for intracranial aneurysms located in the posterior cerebral circulation. At clinical presentation, headache was the prevalent symptom (92%), followed by alteration in the level of consciousness (58%) and nausea and vomiting (50%). Among medical comorbidities, patients had hypertension (67%), diabetes mellitus (8%), and obesity (17%). About 33% of patients presented with a poor H\u0026amp;H grading score of III-V (median: II) and a median Fisher grading score of 3 (IQR 1\u0026ndash;4). Detailed information on the patient\u0026acute;s demographics and clinical features is shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eA total of 15 aneurysms were described, including 13 in the posterior circulation coexisting with 2 in the anterior circulation. All aneurysms were of saccular morphology; 62% were unruptured, and 25% were multiple. The median size was 7.9 mm\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3 (5.6\u0026ndash;13.6 mm). The predominant location was the basilar artery (62%), followed by the posterior inferior cerebellar artery (15%) and the posterior cerebral artery at the P1 (15%) and P1-P2 segments (8%) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient demographics and clinical information at presentation.\u003c/strong\u003e \u003csup\u003e1\u003c/sup\u003emean \u0026plusmn; SD (range); \u003csup\u003e2\u003c/sup\u003e median (interquartile range, IQR).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u0026nbsp;(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e9 (75%)\u003c/p\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5 (43\u0026ndash;63)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinical Presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeadache\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(91.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNausea and vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlteration of the level of consciousness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical comorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObesity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHunt and Hess Grading Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI2 (1\u0026ndash;4) \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModified Fisher Grading scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (1\u0026ndash;4) \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eAneurysms\u0026rsquo; Characteristics.\u003c/strong\u003e \u003csup\u003e1\u003c/sup\u003e mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRupture status at presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRuptured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnruptured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiplicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMorphology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSacular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSize (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 (5.6\u0026ndash;13.6)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u0026ndash;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBasilar artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePosterior cerebral artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP1 segment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP2 segment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePosterior inferior cerebellar artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eSurgical details\u003c/h2\u003e\n \u003cp\u003eA pterional craniotomy (75%) was the predominant approach, followed by a suboccipital craniotomy (17%) and decompressive craniectomy (8%). To corroborate vascular supply in the adjacent aneurysm territory and perforators, intraoperative video angiography with fluorescein (infusion rate: 125mg/2.5cc) was utilized post-clipping of aneurysms.\u003c/p\u003e\n \u003cp\u003eAmong intraoperative complications, 17% of patients experienced aneurysm rupture, which was promptly controlled. Postoperative complications included hydrocephalus (17%), cerebral infarction (25%), infection (8%), and cerebrospinal fluid fistula (8%). Two patients died because of cerebral vasospasm, cerebral infarction, and intracranial hypertension (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Techniques, outcomes, and follow-up.\u003c/strong\u003e mRS\u0026thinsp;=\u0026thinsp;modified Rankin Scale score. \u003csup\u003e1\u003c/sup\u003e mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePterional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuboccipital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCraniectom\u0026iacute;a descompresiva\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical details\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClipping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraoperative visualization tools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVideoangiography with fluorescein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOperative time (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1,82 (1,5\u0026ndash;10,8) \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraoperative aneurysm rupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRebleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCerebral infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCerebrospinal fluid fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAneurysm Obliteration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComplete\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinical outcome at hospital discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Good (mRS 0\u0026ndash;2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Poor (mRS 3\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026bull; Death (mRS 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAneurysm recurrence at 6-month follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eClinical outcomes and Follow-up\u003c/h2\u003e\n \u003cp\u003eAt hospital discharge, most patients had a mRS 0\u0026ndash;2 (66.7%), followed by a mRS 3\u0026ndash;5 (16.7%) and mRS 6 (16.7%). At the six-month follow-up, 90% of patients had a mRS 0\u0026ndash;2 and 10% had a mRS 3\u0026ndash;5 (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients\u0026rsquo; details regarding approaches utilized, postoperative complications, and neurological outcomes.\u003c/strong\u003e CI: cerebral infarction, F: female; M: male mRS: modified Rankin scale; IH: Intracranial hypertension; Ptnl: pterional; SO: suboccipital\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSurgical approach\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostoperative complications\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003emRS at discharge\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003emRS at 6 months\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDecompressive craniotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCI and IH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCI and IH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePtnl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eIllustrative cases\u003c/h2\u003e\n \u003cp\u003eMicrosurgical management of aneurysms was evaluated based on the patient\u0026acute;s clinical history and aneurysm features such as rupture status, multiplicity, large size, presence of a wide neck, and progressive neurological deterioration as suggestive of increasing mass effect.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eCase 1\u003c/h2\u003e\n \u003cp\u003eA 44-year-old female presented with a sudden headache and vomiting. Upon clinical examination and brain imaging, the patient had a Glasgow Coma Scale (GCS) score of 15, a H\u0026amp;H score of I, and a World Federation of Neurosurgical Societies (WFNS) score of I. A cerebral angiotomography showed a ruptured saccular aneurysm in the P1-P2 segment of the PCA (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe patient underwent a right frontal-temporal-zygomatic craniotomy with a broad dissection of the Sylvian fissure. Access to the carotid-oculomotor cistern was enabled, followed by gentle dissection of the Liliquiest\u0026rsquo;s membrane. We performed proximal temporal control of the basilar artery and aneurysm neck clipping within the posterior fossa. Finally, fluorescein angiography and endoscopy corroborated vascular permeability in collateral and perforators (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eOn follow-up, the patient had right oculomotor nerve paresis with a mRS of 1 at hospital discharge. A 3-month follow-up demonstrated improvement in the oculomotor nerve function. A 6-month follow-up showed the patient had full neurological recovery (mRS: 0).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eCase II\u003c/h2\u003e\n \u003cp\u003eA 58-year-old male presented with a sudden headache, alteration in the level of consciousness, and vomiting. His medical history was remarkable for uncontrolled hypertension. Upon examination, he had a GCS of 8, 3/5 quadriparesis, H\u0026amp;H score of IV, and WFNS of IV, which prompted neurointensive care.\u003c/p\u003e\n \u003cp\u003eBrain imaging suggested the presence of SAH Fisher grade IV with a frontoparietal hematoma and intraventricular hemorrhage. Besides, it depicted a 12x7mm distal fusiform aneurysm in an accessory A2 branch stemming from the anterior communicating complex and a 3.3x3.8mm saccular aneurysm in the distal portion of the basilar artery (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe patient underwent a pterional craniotomy with ample exposure to the temporal bone base. After carefully dissecting the Sylvian fissure and gaining exposure to the anterior communicating complex, clipping of the accessory A2 branch was performed proximally. Subsequently, after gentle dissection of the Liliquiest\u0026acute;s membrane and access to the posterior fossa, we clipped the distal basilar aneurysm neck. In both surgical stages, fluorescein video angiography confirmed the patency of the permeability of the adjacent vascular supply (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eOn follow-up, the patient was discharged with a GSC of 13, 4/5 quadriparesis, and right oculomotor paresis. At 6-month follow-up, the patient had a mRS of 2 and complete recovery of the oculomotor nerve paresis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eCase III\u003c/h2\u003e\n \u003cp\u003eA 75-year-old female presented with a sudden headache and loss of consciousness. On examination, the patient had H\u0026amp;H of I. Brain imaging showed intraventricular hemorrhage, hydrocephalus, and a ruptured saccular basilar apex aneurysm (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe patient underwent a right personal approach with extradural anterior clinoidectomy and dissection of the distal dural ring. After recognition of the vascular lesion and identification of the aneurysms, a permanent clip was applied (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eOn follow-up, the patient had a favorable clinical evolution with a mRS of 2 at six months.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePosterior circulation aneurysms constitute about 3.8\u0026ndash;15% of intracranial aneurysms and carry a higher risk of rupture than those located in the anterior circulation.\u003csup\u003e3,4,11,16\u0026ndash;18\u003c/sup\u003e Notably, given their anatomical location, proximity to vital structures, reduced space in the cranial fossa, and mass effect, they can be associated with poorer clinical outcomes.\u003csup\u003e5\u003c/sup\u003e Furthermore, rupture risk can be increased depending on the patient\u0026acute;s ethnicity. For instance, in the Japanese population, the rupture risk can be 2.5 times greater than in the general population.\u003csup\u003e19\u003c/sup\u003e The risk can also be higher depending on the aneurysm location. A study showed that among unruptured aneurysms, those in the basilar apex and superior cerebellar artery had an annual rupture rate of 6.9%.\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTreatment strategies include microsurgical and endovascular techniques. The latter has been increasingly adopted because of its minimally invasive approach.\u003csup\u003e21,22\u003c/sup\u003e However, in aneurysms with wide neck, thrombosed, giant-sized, involving perforators and branches, endovascular treatment can be limited to provide complete aneurysm occlusion with greater recurrence and rebleeding rates.\u003csup\u003e9,10,23,24\u003c/sup\u003e Furthermore, the need for antiaggregating therapy can be associated with bleeding.\u003csup\u003e25\u003c/sup\u003e On the other hand, microsurgical management can be beneficial for select cases with a greater occlusion rate, less likelihood of recurrence, and lesser risk of rebleeding and hydrocephalus.\u003csup\u003e26,27\u003c/sup\u003e Tsianaka et al. performed a meta-analysis comparing endovascular coiling to microsurgical clipping of posterior circulation aneurysms. Statistical analysis yielded significantly better outcomes regarding permanent neurological deficit when treated with coiling, but clipping was associated with better outcomes concerning reintervention.\u003csup\u003e28\u003c/sup\u003e Therefore, there is no conclusive answer to which is the overall better option for every patient. Current literature presents heterogeneity in terms of sample sizes, baseline characteristics of the patients (presentation, age, sex, comorbidities, ethnicity, etc), and neurosurgeon skill. Future studies should aim to provide larger sample sizes, multivariate and subgroup analyses, and longer follow-up periods.\u003c/p\u003e \u003cp\u003eShifting to flow-diverters, they are currently gaining significant attention, but results for aneurysms of the posterior circulation are still not completely encouraging.\u003csup\u003e29\u0026ndash;31\u003c/sup\u003e For complex aneurysms, when conventional strategies are unsuitable, considering the outcomes, open surgery revascularizations are an adequate option for skilled neurosurgeons,\u003csup\u003e32\u003c/sup\u003e mainly in limited-resource countries.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhen comparing endovascular to surgical approaches for PICA aneurysms, Saal-Zapata et al. demonstrated that the literature, despite extensive, carries a serious risk of bias. Hence, the authors emphasize the case-by-case and institutional experience value when choosing the preferable treatment option.\u003csup\u003e33\u003c/sup\u003e Moreover, another systematic review and meta-analysis comparing treatments for PICA saccular aneurysms conducted by Ali et al. showcased microsurgical clipping resulting in superior angiographic outcomes and similar functional outcomes but higher rates of lower cranial nerve palsy compared with EVT.\u003csup\u003e34\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe authors acknowledge the results of this study are limited by its retrospective and observational nature and the small sample size of patients. Nevertheless, the relevant insights from this institutional experience are worth highlighting. While endovascular treatment has emerged as an innovative approach for posterior circulation aneurysms, consideration of the clinical setting is an essential factor within the decision-making process in low-to-middle-income countries. Consequently, microsurgery has a remarkable and manifest role in such settings as the only treatment of choice. While this may bring controversy to providing optimal treatment, the associated setting pressure can represent an opportunity for neurosurgeons to strive for microsurgical mastery and gain a competitive advantage.\u003csup\u003e35\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the modern era of the treatment of posterior circulation aneurysms, endovascular techniques have shown favorable outcomes compared with microsurgery for select cases. However, amid the limited availability of endovascular devices in low-to-middle-income countries, microsurgery remains the treatment of choice.\u003c/p\u003e \u003cp\u003eThe present case series illustrates optimal microsurgical management of patients from low-income backgrounds affected by posterior circulation brain aneurysms. Notably, the manifest role of microsurgery inherently exhorts neurosurgeons in training to achieve a high level of microsurgical mastery to provide safe patient treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was provided for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u0026nbsp;\u003c/strong\u003eFigures 2A,2B, 2D, and 2E are licensed under theCreative Commons CC BY, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A link to the recently published article is provided: https://academic.oup.com/jscr/article/2024/1/rjad742/7560344\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSharma D, Singh D, Jagetia A, Singh H, Tandon M, Ganjoo P. Intra procedure rupture of intracranial aneurysm during endovascular coiling: Neurosurgeons experience and review of the literature. \u003cem\u003eNeurol INDIA\u003c/em\u003e. 2011;59(5):42-47. doi:10.4103/0028-3886.86542\u003c/li\u003e\n\u003cli\u003eEtminan N, Brown RD, Beseoglu K, et al. The unruptured intracranial aneurysm treatment score. \u003cem\u003eNeurology\u003c/em\u003e. 2015;85(10):881-889. doi:10.1212/WNL.0000000000001891\u003c/li\u003e\n\u003cli\u003eGreving JP, Wermer MJH, Brown RD, et al. Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2014;13(1):59-66. doi:10.1016/S1474-4422(13)70263-1\u003c/li\u003e\n\u003cli\u003eMolyneux AJ, Kerr RSC, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. \u003cem\u003eLancet Lond Engl\u003c/em\u003e. 2005;366(9488):809-817. doi:10.1016/S0140-6736(05)67214-5\u003c/li\u003e\n\u003cli\u003eWilliamson RW, Wilson DA, Abla AA, et al. Clinical characteristics and long-term outcomes in patients with ruptured posterior inferior cerebellar artery aneurysms: a comparative analysis. \u003cem\u003eJ Neurosurg\u003c/em\u003e. 2015;123(2):441-445. doi:10.3171/2014.10.JNS141079\u003c/li\u003e\n\u003cli\u003eBijlenga P, Ebeling C, Jaegersberg M, et al. Risk of rupture of small anterior communicating artery aneurysms is similar to posterior circulation aneurysms. \u003cem\u003eStroke\u003c/em\u003e. 2013;44(11):3018-3026. doi:10.1161/STROKEAHA.113.001667\u003c/li\u003e\n\u003cli\u003eWaqas M, Monteiro A, Cappuzzo JM, Tutino VM, Levy EI. Evolution of the patient-first approach: a dual-trained, single-neurosurgeon experience with 2002 consecutive intracranial aneurysm treatments. \u003cem\u003eJ Neurosurg\u003c/em\u003e. 2022;137(6):1751-1757. doi:10.3171/2022.2.JNS22105\u003c/li\u003e\n\u003cli\u003eMolyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. \u003cem\u003eLancet Lond Engl\u003c/em\u003e. 2002;360(9342):1267-1274. doi:10.1016/s0140-6736(02)11314-6\u003c/li\u003e\n\u003cli\u003eMolyneux AJ, Birks J, Clarke A, Sneade M, Kerr RSC. The durability of endovascular coiling versus neurosurgical clipping of ruptured cerebral aneurysms: 18 year follow-up of the UK cohort of the International Subarachnoid Aneurysm Trial (ISAT). \u003cem\u003eLancet Lond Engl\u003c/em\u003e. 2015;385(9969):691-697. doi:10.1016/S0140-6736(14)60975-2\u003c/li\u003e\n\u003cli\u003eSpetzler RF, McDougall CG, Albuquerque FC, et al. The Barrow Ruptured Aneurysm Trial: 3-year results. \u003cem\u003eJ Neurosurg\u003c/em\u003e. 2013;119(1):146-157. doi:10.3171/2013.3.JNS12683\u003c/li\u003e\n\u003cli\u003eWiebers DO, Whisnant JP, Huston J, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. \u003cem\u003eLancet Lond Engl\u003c/em\u003e. 2003;362(9378):103-110. doi:10.1016/s0140-6736(03)13860-3\u003c/li\u003e\n\u003cli\u003eBender MT, Wendt H, Monarch T, et al. Shifting Treatment Paradigms for Ruptured Aneurysms from Open Surgery to Endovascular Therapy Over 25 Years. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2017;106:919-924. doi:10.1016/j.wneu.2017.07.074\u003c/li\u003e\n\u003cli\u003eFerreira T, Awuah WA, Tan JK, et al. The current landscape of intracranial aneurysms in Africa: management outcomes, challenges, and strategies-a narrative review. \u003cem\u003eNeurosurg Rev\u003c/em\u003e. 2023;46(1):194. doi:10.1007/s10143-023-02102-4\u003c/li\u003e\n\u003cli\u003eGon\u0026ccedil;alves B, Rynkowski C, Turon R, et al. Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country. \u003cem\u003eNeurocrit Care\u003c/em\u003e. 2023;38(2):378-387. doi:10.1007/s12028-022-01629-6\u003c/li\u003e\n\u003cli\u003eLabib MA, Rumalla K, Karahalios K, et al. Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2022;91(3):470-476. doi:10.1227/neu.0000000000002061\u003c/li\u003e\n\u003cli\u003eEller JL, Dumont TM, Mokin M, et al. Endovascular treatment of posterior circulation aneurysms. \u003cem\u003eNeurol Res\u003c/em\u003e. 2014;36(4):339-343. doi:10.1179/1743132814Y.0000000323\u003c/li\u003e\n\u003cli\u003eBrown RD, Broderick JP. Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2014;13(4):393-404. doi:10.1016/S1474-4422(14)70015-8\u003c/li\u003e\n\u003cli\u003eSonobe M, Yamazaki T, Yonekura M, Kikuchi H. Small unruptured intracranial aneurysm verification study: SUAVe study, Japan. \u003cem\u003eStroke\u003c/em\u003e. 2010;41(9):1969-1977. doi:10.1161/STROKEAHA.110.585059\u003c/li\u003e\n\u003cli\u003ede Rooij NK, Linn FHH, van der Plas JA, Algra A, Rinkel GJE. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. \u003cem\u003eJ Neurol Neurosurg Psychiatry\u003c/em\u003e. 2007;78(12):1365-1372. doi:10.1136/jnnp.2007.117655\u003c/li\u003e\n\u003cli\u003eUCAS Japan Investigators, Morita A, Kirino T, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2012;366(26):2474-2482. doi:10.1056/NEJMoa1113260\u003c/li\u003e\n\u003cli\u003eHua X, Gray A, Wolstenholme J, et al. Survival, Dependency, and Health-Related Quality of Life in Patients With Ruptured Intracranial Aneurysm: 10-Year Follow-up of the United Kingdom Cohort of the International Subarachnoid Aneurysm Trial. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2021;88(2):252-260. doi:10.1093/neuros/nyaa454\u003c/li\u003e\n\u003cli\u003eSpetzler RF, McDougall CG, Zabramski JM, et al. Ten-year analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. \u003cem\u003eJ Neurosurg\u003c/em\u003e. 2019;132(3):771-776. doi:10.3171/2018.8.JNS181846\u003c/li\u003e\n\u003cli\u003eMascitelli JR, Lawton MT, Hendricks BK, Nakaji P, Zabramski JM, Spetzler RF. Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2019;85(5):622-631. doi:10.1093/neuros/nyy439\u003c/li\u003e\n\u003cli\u003eShi X, Qian H, Singh KCKI, et al. Surgical management of vertebral and basilar artery aneurysms: a single center experience in 41 patients. \u003cem\u003eActa Neurochir (Wien)\u003c/em\u003e. 2013;155(6):1087-1093. doi:10.1007/s00701-013-1656-6\u003c/li\u003e\n\u003cli\u003eGross BA, Frerichs KU. Stent usage in the treatment of intracranial aneurysms: past, present and future. \u003cem\u003eJ Neurol Neurosurg Psychiatry\u003c/em\u003e. 2013;84(3):244-253. doi:10.1136/jnnp-2011-302007\u003c/li\u003e\n\u003cli\u003eLi H, Pan R, Wang H, et al. Clipping versus coiling for ruptured intracranial aneurysms: a systematic review and meta-analysis. \u003cem\u003eStroke\u003c/em\u003e. 2013;44(1):29-37. doi:10.1161/STROKEAHA.112.663559\u003c/li\u003e\n\u003cli\u003eJiang Z, Chen Y, Zeng C, Feng J, Wan Y, Zhang X. Neurosurgical Clipping versus Endovascular Coiling for Patients with Intracranial Aneurysms: A Systematic Review and Meta-Analysis. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2020;138:e191-e222. doi:10.1016/j.wneu.2020.02.091\u003c/li\u003e\n\u003cli\u003eTsianaka E, Al-Shawish A, Potapov A, Fountas K, Spyrou M, Konovalov N. Clipping versus coiling in posterior circulation intracranial aneurysms: a meta-analysis. \u003cem\u003eChin Neurosurg J\u003c/em\u003e. 2019;5:16. doi:10.1186/s41016-019-0163-x\u003c/li\u003e\n\u003cli\u003eKiyofuji S, Graffeo CS, Perry A, et al. Meta-analysis of treatment outcomes of posterior circulation non-saccular aneurysms by flow diverters. \u003cem\u003eJ Neurointerventional Surg\u003c/em\u003e. 2018;10(5):493-499. doi:10.1136/neurintsurg-2017-013312\u003c/li\u003e\n\u003cli\u003eWang CB, Shi WW, Zhang GX, Lu HC, Ma J. Flow diverter treatment of posterior circulation aneurysms. A meta-analysis. \u003cem\u003eNeuroradiology\u003c/em\u003e. 2016;58(4):391-400. doi:10.1007/s00234-016-1649-2\u003c/li\u003e\n\u003cli\u003eAbdel-Tawab M, Abdeltawab AK, Abdelmonem M, et al. Efficacy and safety of flow diverters in posterior circulation aneurysms and comparison with their efficacy in anterior circulation aneurysms: A systematic review and meta-analysis. \u003cem\u003eInterv Neuroradiol J Peritherapeutic Neuroradiol Surg Proced Relat Neurosci\u003c/em\u003e. 2021;27(5):609-621. doi:10.1177/15910199211003017\u003c/li\u003e\n\u003cli\u003eOliveira L de B, Sousa MP, Ribas LRC, et al. Efficacy and Safety of Extracranial-Intracranial Bypass Surgery for Posterior Circulation Aneurysms: A Systematic Review and Single-Arm Meta-Analysis. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2023;183:15-28. doi:10.1016/j.wneu.2023.12.002\u003c/li\u003e\n\u003cli\u003eSaal-Zapata G, Rodriguez-Calienes A, Malaga M, et al. Microsurgical and endovascular treatment of posterior inferior cerebellar artery aneurysms: a systematic review and meta-analysis. \u003cem\u003eJ Neurosurg Sci\u003c/em\u003e. 2023;67(5):638-652. doi:10.23736/S0390-5616.22.05710-1\u003c/li\u003e\n\u003cli\u003eAli AMS, Hannan CJ, Islim AI, Mascitelli JR, Javadpour M. Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysms: Systematic Review and Meta-Analysis. \u003cem\u003eWorld Neurosurg\u003c/em\u003e. 2022;162:e168-e177. doi:10.1016/j.wneu.2022.02.103\u003c/li\u003e\n\u003cli\u003eAbecassis IJ, Sen RD, Ellenbogen RG, Sekhar LN. Developing microsurgical milestones for psychomotor skills in neurological surgery residents as an adjunct to operative training: the home microsurgery laboratory. \u003cem\u003eJ Neurosurg\u003c/em\u003e. 2020;135(1):194-204. doi:10.3171/2020.5.JNS201590\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Patient demographics and clinical information at presentation.\u0026nbsp;\u003c/strong\u003e\u003csup\u003e1\u003c/sup\u003emean \u0026plusmn; SD (range);\u0026nbsp;\u003csup\u003e2\u003c/sup\u003e median (interquartile range, IQR).\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026nbsp;(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e9 (75%)\u003c/p\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52.4 \u0026plusmn; 7.5 (43-63)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical Presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHeadache\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11(91.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNausea and vomiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAlteration of the level of consciousness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eComa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMedical comorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eObesity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHunt and Hess Grading Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eI2 (1-4) \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eModified Fisher Grading scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (1\u0026ndash;4) \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Aneurysms\u0026rsquo; Characteristics.\u0026nbsp;\u003c/strong\u003e\u003csup\u003e1\u003c/sup\u003e mean \u0026plusmn; SD (range).\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRupture status at presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRuptured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUnruptured\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMultiplicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMorphology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSacular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSize (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.2 \u0026plusmn; 0.6 (5.6-13.6)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u0026ndash;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u0026ndash;24\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBasilar artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (61.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePosterior cerebral artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026emsp;P1 segment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026emsp;P2 segment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePosterior inferior cerebellar artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Surgical Techniques, outcomes, and follow-up.\u0026nbsp;\u003c/strong\u003emRS = modified Rankin Scale score. \u003csup\u003e1\u003c/sup\u003e mean \u0026plusmn; SD (range).\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSurgical approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePterional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSuboccipital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCraniectom\u0026iacute;a descompresiva\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (8.3%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSurgical details\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClipping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIntraoperative visualization tools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVideoangiography with fluorescein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEndoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOperative time (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.10 \u0026plusmn; 1,82 (1,5\u0026ndash;10,8) \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIntraoperative aneurysm rupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePostoperative complications\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRebleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCerebral infarction\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCerebrospinal fluid fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAneurysm Obliteration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eComplete\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical outcome at hospital discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eGood\u0026nbsp;(mRS 0\u0026ndash;2)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003ePoor (mRS 3\u0026ndash;5)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eDeath (mRS 6)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAneurysm recurrence at 6-month follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Patients\u0026rsquo; details regarding approaches utilized, postoperative complications, and neurological outcomes.\u0026nbsp;\u003c/strong\u003eCI: cerebral infarction, F: female; M: male mRS: modified Rankin scale; IH: Intracranial hypertension; Ptnl: pterional; SO: suboccipital\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical approach\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative complications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003emRS at \u0026nbsp;discharge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003emRS at 6 \u0026nbsp;months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003eDecompressive craniotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eCI and IH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003eSO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eCI and IH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003eSO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eHydrocephalus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.701940035273369%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.640211640211641%\" valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.289241622574956%\" valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.929453262786595%\" valign=\"top\"\u003e\n \u003cp\u003ePtnl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.693121693121693%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.400352733686066%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.345679012345679%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Brain aneurysms, Basilar artery, Microsurgery, Posterior cerebral artery, Posterior inferior cerebellar artery, Global Neurosurgery","lastPublishedDoi":"10.21203/rs.3.rs-3922549/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3922549/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground and objective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAneurysms of the posterior cerebral circulation constitute a burdensome condition with high mortality and morbidity. In the modern area of sophisticated technological advancements, there has been a trend toward favoring an endovascular approach over microsurgery for aneurysm cases. Nevertheless, this transition has yet to be mirrored in low-to-middle-income countries where endovascular therapy may not be widely available. Herein, we aim to illustrate our experience treating these challenging conditions in patients from low-income backgrounds and discuss the relevance of considering the clinical setting in the treatment decision algorithm.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe authors conducted a retrospective review of the health records of patients receiving microsurgical treatment for aneurysms in the posterior circulation, including the basilar artery (BA), posterior cerebral artery (PCA), and posterior inferior cerebellar artery (PICA) in an institution providing treatment to people of low-income backgrounds. Epidemiological data, microsurgical technique, and neurological function were retrieved and analyzed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSurgical clipping was employed for 12 patients (75% female) harboring 15 aneurysms (87% in the posterior circulation and 62% ruptured at presentation). Aneurysms were predominately located in the BA (62%), followed by the PCA (23%) and PICA (15%). Among neurological complications, 25% of patients developed paresis of the oculomotor nerve. The mortality rate was 17% owing to complications such as cerebral vasospasm, infarction, and severe intracranial hypertension. At the 6-month follow-up, 90% of patients had a good clinical outcome (modified Rankin scale score of 0\u0026ndash;2).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe present case series illustrates the manifest role of microsurgical techniques for posterior circulation aneurysms, particularly in a scenario where endovascular techniques are not yet available. Importantly, this clinical setting pressure can provide an imperative need to strive for microsurgical mastery and an opportunity for neurosurgeons in training to gain a competitive advantage.\u003c/p\u003e","manuscriptTitle":"When Microsurgery Becomes the Only Lifesaving Resource: An Institutional Experience Treating Patients from Low-Income Backgrounds Affected by Posterior Circulation Brain Aneurysms","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-06 17:23:34","doi":"10.21203/rs.3.rs-3922549/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"54cd831e-e087-48dd-817a-cc97ca194cf8","owner":[],"postedDate":"February 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":28546052,"name":"Neurosurgery"}],"tags":[],"updatedAt":"2024-07-11T18:47:53+00:00","versionOfRecord":{"articleIdentity":"rs-3922549","link":"https://doi.org/10.1016/j.jocn.2024.06.014","journal":{"identity":"journal-of-clinical-neuroscience","isVorOnly":true,"title":"Journal of Clinical Neuroscience"},"publishedOn":"2024-08-01 18:47:53","publishedOnDateReadable":"August 1st, 2024"},"versionCreatedAt":"2024-02-06 17:23:34","video":"","vorDoi":"10.1016/j.jocn.2024.06.014","vorDoiUrl":"https://doi.org/10.1016/j.jocn.2024.06.014","workflowStages":[]},"version":"v1","identity":"rs-3922549","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3922549","identity":"rs-3922549","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}