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Fig. 14.8 Orbitozygomatic approach to a basilar apex
aneurysm. A 61-year-old woman with history of more
than 40 pack-years of smoking presented for evaluation
after workup for headaches. (a, b) Magnetic resonance
angiography revealed two aneurysms, a right middle cere-
bral artery (MCA) aneurysm (dashed arrow) and a basilar
apex aneurysm (solid arrow). The lesions were approached
using a right orbitozygomatic craniotomy. After the
Sylvian fissure was widely split, three operative corridors
to the basilar apex were explored. These included the
supracarotid, carotico- oculomotor, and optico-carotid
working corridors. Next, the arachnoid on the medial sur-
face of the third nerve was dissected to allow it to fall
away with the temporal lobe. (c) After Liliequist’s mem-
brane was opened, the contents of the posterior fossa,
including the basilar apex aneurysm, were identified. The
basilar perforators, emanating from the posterior surface
of the basilar artery, were carefully dissected prior to
application of the clip. (d) Indocyanine green angiogra-
phy revealed occlusion of the basilar apex aneurysm (long
arrows) and preservation of the flow in the perforator.
Postoperatively, the patient was neurologically intact. (e)
Postoperative computed tomography angiography dem-
onstrated complete occlusion of the aneurysm, and (f)
postoperative magnetic resonance imaging revealed no
infarction (a, b, e, f are used with permission from Journal
of Neurosurgery, and c, d are used with permission from
Barrow Neurological Institute, Phoenix, Arizona)M.Y.S. Kalani and R.F. Spetzler