Abstract
Flow diversion is an effective treatment for well-selected intracranial aneurysms,(1) including certain unruptured posterior circulation lesions.(2,3) In spite of improvements in flow diverters, treatment failure remains a long-term risk, and data regarding aneurysm retreatment with multiple additional devices are limited.(4) Aneuryms refractory to endovascular intervention present complex clinical challenges that frequently mandate open strategies. A 7-mm basilar apex aneurysm was diagnosed in a woman in her mid 60s who presented with severe headache and subarachnoid hemorrhage. She underwent incomplete coil embolization of the aneurysm (Raymond-Roy II) and made a complete neurological recovery; the initial follow-up plan was for repeat angiography at 6 months. Recanalization of the aneurysm was noted at that time, prompting secondary endovascular treatment with flow diversion. This failed to obliterate the lesion, leading to tertiary endovascular treatment with a second flow diverter at 12 months after the initial treatment. Despite these serial interventions, persistent aneurysm filling and interval growth were observed. Open cerebrovascular treatment was recommended, with consideration for flow reversal vs clip reconstruction using left orbitozygomatic craniotomy. The superficial temporal artery was harvested for possible bypass. Excellent access was established after anterior clinoidectomy, sphenoparietal sinus transposition, wide sylvian fissure dissection, and posterior clinoidectomy. After thalamoperforator dissection, adequate exposure was achieved for safe primary clip reconstruction, and a picket fence technique combining carotid-oculomotor and oculomotor-tentorial corridors was used. Indocyanine green videoangiography confirmed obliteration of the aneurysm and patency of all adjacent vascular structures, and the patient recovered without neurological deficit. The patient gave informed consent for the procedure. Video used with permission from Barrow Neurological Institute.