Topography of the medial loop of the internal carotid artery and posterior clinoid processes: transcavernous approach
Despite significant progress in the treatment of intracranial arterial aneurysms (AAs) using various endovascular methods (including stent-assisted coiling and balloon-assisted coiling, installation of flow-diverting stents, development of new microcatheters and microcoils, novel stenting techniques (such as jailed-catheter technique and trans-cell technique for arterial wall reconstruction and Y-stent&waffle-cone technique and X-stent technique for stenting AA bifurcations)) and the use of new endovascular techniques for hemodynamic remodeling in AAs (including WEB - device, PED - Pipeline Embolization Device), the results of endovascular AA occlusion assessed using the Raymond Montreal scale remain unsatisfactory (class II (residual neck), class III (residual AA), recanalizations and re-operations (CLARITY (2011), ATENA (2009), AHA (2015), ISAT (2009), CARAT (2008), BRAT (2012), BRAT-3 (2014)). Microsurgical clipping of AA ensures better aneurysm exclusion (Raymond class I) compared to endovascular treatment. However, the use of standard approaches to basilar artery (BA) AA is limited due to high mortality and morbidity. Currently, with the development of skull base surgery, basal approaches are successfully used to ensure the access, dissection and exclusion of an AA from the bloodstream using a clip. Clear techniques of the basal approach, interventions only at optimal sites of the skull base, expansion of standard surgical gaps, different methods of traction of the basal brain make the basal approach indispensable. This article describes the most popular types of basal approaches to the BA apex with a description of the technique developed by the author. These approaches ensure exclusion of an AA from the bloodstream (Raymond class I) with good and excellent treatment outcomes (GOS-Glasgow Outcome Scale, Rankin scale).