• Ricardo Chmelnitsky Wainberg, da CostaMarcos Devanir SilvaMDSDepartment of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo-SP, Brazil. Postal adress: Doutor Diogo de Faria, 775, conjunto 91, 04037-002, São Paulo-SP, Brazil. Electronic address: marcoscostaneuro@gmail.com., Mauricio Marchiori, Ricardo Bernardi Soder, José Maria de Campos Filho, Hugo Leonardo Doria Netto, Eliseu Paglioli Neto, and Feres Chaddad-Neto.
• Service of Neurosurgery, Hospital São Lucas da PUCRS, Porto Alegre-RS, Brazil. Postal adress: Avenida Ipiranga, 6690, Centro Clínico, conjunto 306, 90610-000, Porto Alegre, Brazil.
• World Neurosurg. 2018 Dec 31.

AbstractBasilar bifurcation is a challenging site for aneurysm clipping. Anatomical factors such as size and projection of the aneurysm, distance between the aneurysm neck and the dorsum sellae, and location of the basilar bifurcation contribute to surgical complexity. Endovascular treatment has been used more frequently than microsurgical clipping, especially for posterior circulation lesions. Thus, the upcoming generation of neurosurgeons will have increasingly less access to the microsurgical treatment of such lesions. We present the case of a 45-year-old female patient who presented sudden mental confusion characterized by disorientation in time, space, and person. Investigative acute cerebral magnetic resonance imaging revealed diffusion restriction in the left posterior cerebral and superior cerebellar arteries. The clinical and cardiologic investigations revealed no abnormalities, but computed tomographic angiography and digital arteriography revealed a low-riding basilar bifurcation aneurysm and a very small aneurysm in the right internal carotid artery. The wide neck precluded coil embolization, and the appropriate stent was not covered by our public health insurance. Considering the young age, surgical treatment was proposed. Microsurgical clipping was performed using the right pre-temporal approach. In this two-dimensional video, we show the steps to reach the low-riding basilar bifurcation aneurysm neck. The positioning, transzygomatic pterional craniotomy, intradural anterior clinoidectomy, and posterior cavernous sinus opening are shown, and the surrounding anatomy is illustrated.Copyright © 2018 Elsevier Inc. All rights reserved.

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