How I do it: the endoscopic endonasal transclival approach for clipping of the ruptured vertebral artery aneurysm.

BACKGROUND: Vertebral artery aneurysms account for less than 5% of all cerebral aneurysms. They have a high risk of rupture and are associated with threatening clinical outcomes compared with anterior circulation aneurysms. METHOD: The endoscopic endonasal transclival approach (EETA) was used. During the temporary clipping, the neck of the aneurysm was dissected, and a permanent clip was applied. The repair of the skull base defect was carried out with the nasoseptal mucoperiosteal flap on the vascular pedicle. CONCLUSION: The EETA is a feasible alternative for the clipping of the medially located ruptured vertebral artery aneurysm. EETA can be recommended for centers with a large volume of cerebrovascular and endoscopic neurosurgical procedures.

How I do it: The microsurgical clipping of the giant paraclinoid aneurysm using the retrograde suction decompression technique.

BACKGROUND: Paraclinoid aneurysms account for 5.4% of all intracranial aneurysms. Giant aneurysms are found in 49% of these cases. The 5-year cumulative rupture risk is 40%. Microsurgical treatment of paraclinoid aneurysms is a complex challenge that requires a personalized approach. METHOD: Extradural anterior clinoidectomy and optic canal unroofing were performed in addition to orbitopterional craniotomy. Falciform ligament and distal dural ring transection provided the internal carotid artery and optic nerve mobilization. Retrograde suction decompression was used to soften the aneurysm. Clip reconstruction was performed using tandem angled fenestration and parallel clipping techniques. CONCLUSION: Orbitopterional approach with extradural anterior clinoidectomy combined with retrograde suction decompression technique is a safe and effective modality for treatment of giant paraclinoid aneurysms.