Concept and prospects in open surgery for cerebral aneurysms to prevent complications

Abstract

Clipping is established as the most reliable method for the obliteration of cerebral saccular aneurysms. For surgical safety, anatomical structures around an aneurysm should be visualized under intracranial pressure control, and dissection of an aneurysm circumferentially is essential to provide the aneurysm with mobility and to secure a wide operative field. The procedure to detach perforators from a cerebral aneurysm wall is the most critical technique in the appropriate clipping strategy. Non-invasive preoperative evaluation using high-resolution MRI including 3T and 7T MRI is useful for the evaluation of the aneurysmal wall and perforators, respectively. Intraoperative monitoring of cerebral cortical blood flow and middle cerebral artery pressure may be useful, along with preoperative balloon test occlusion, for patients with unclippable internal carotid artery aneurysms, including thrombosed or blister-like aneurysms. The best treatment strategies for complex dissection in the posterior circulation that require artery occlusion with revascularization should be discussed between the surgical team and the endovascular team. The current status and future prospects of the surgical treatment of cerebral aneurysms are reviewed.