Video Section-Operative Nuances: Step by Step – Single Stage Clipping of Ruptured Middle Cerebral Artery and Unruptured Basilar Top Aneurysm

BACKGROUND AND INTRODUCTION: Presence of multiple aneurysms, especially a combination of anterior and posterior circulation aneurysm in the same patient, is rare. Surgical clipping of both the aneurysms in the same sitting, although ideal, may be surgically challenging and requires a good preoperative planning. OBJECTIVE: In this video abstract, we present a case of a ruptured middle cerebral artery (MCA) aneurysm with a simultaneous occurrence of an unruptured basilar top aneurysm. SURGICAL TECHNIQUE: A 45-year-old female presented with modified Hunt and Hess grade II subarachnoid hemorrhage (SAH). CT scan showed diffuse SAH with a dense bleed in the left sylvian cistern and mild hydrocephalus. Angiography showed a left MCA aneurysm (34 mm size) with a bleb and also an un-ruptured basilar bifurcation/right posterior cerebral artery aneurysm (20 mm). The patient underwent a left frontotemporal craniotomy, zygomatic osteotomy, and clipping of both aneurysms. No temporary clips were applied. The extended craniotomy allowed the surgeon to reach to the base of the aneurysm. RESULTS: The patient had an uneventful recovery. CONCLUSIONS: Simultaneous occurrence of both anterior and posterior circulation aneurysms are rare, but maybe tackled surgically with proper planning.