Surgical management of bilateral middle cerebral artery aneurysms via a unilateral supraorbital key-hole craniotomy.

INTRODUCTION: Surgical management of multiple intracranial aneurysms may be difficult if located bilaterally. In the case of bilateral middle cerebral artery (MCA) aneurysms, surgical treatment through a unilateral approach is generally not recommended. In this study we describe the surgical technique and important factors that enable treatment of bilateral MCA aneurysms via a unilateral key-hole approach. PATIENTS AND METHODS: 15 patients (12 females, 3 males) with bilateral aneurysms of the MCA were surgically treated via a supraorbital key-hole approach. Age ranged from 37 to 60 years (mean: 47). 7 of the 15 patients presented with an acute subarachnoid hemorrhage (SAH). Cerebral angiography was performed in all patients pre- and postoperatively. Patients suffering from SAH were treated within the first 72 h. All 15 patients were planned to be operated via a unilateral supraorbital keyhole craniotomy using an eye-brow incision.
RESULTS: In 10 of the 15 patients MCA aneurysms of both sides could be occluded completely through the unilateral approach. In 5 patients bilateral craniotomies had to be performed, in 1 of these patients during the same procedure. Factors necessitating a second craniotomy were brain swelling (1 patient with SAH), insufficient instruments (2 patients), and complex configuration of the contralateral aneurysm (2 patients). Permanent morbidity was anosmia in 1 patient and hyposmia and a mild visual field deficit in 1 further patient.
CONCLUSION: Bilateral aneurysms of the MCA may be treated sufficiently through a unilateral supraorbital key-hole approach in selected patients. This is also possible in patients presenting with SAH. Factors necessitating bilateral craniotomies were brain swelling and complex configuration of the contralateral aneurysm. Copyright Georg Thieme Verlag KG Stuttgart. New York.