Additional videos for this topic are available online at . Indications Symptomatic intracerebral hemorrhage (ICH) causing progressive neurologic symptoms or impending cerebral herniation syndromes is best managed with open evacuation, especially in younger patients. ICH that is associated with suspected underlying structural etiology (vascular malformation, tumor, aneurysm) is best managed with open surgical evacuation, allowing evacuation of hematoma and addressing the underlying structural lesion as…

The authors wish to thank Takanori Fukushima for work on the previous edition’s version of this chapter. Additional videos for this topic are available online at . Indications Despite advances in endovascular neurosurgery, cerebral bypass operations remain essential components in the management of giant aneurysms and some skull base tumors involving the carotid artery. Sacrifice of the internal carotid artery (ICA), either inadvertently or in…

Indications Atherosclerotic carotid artery occlusion with hemodynamic insufficiency in patients that have suffered symptomatic ischemia despite best medical therapy. In nonselected patient populations, a multicenter randomized controlled trial showed no benefit of superficial temporal artery–middle cerebral artery (STA–MCA) bypass for patients with symptomatic carotid occlusive disease. The Carotid Occlusion Surgery Study was designed to examine the effect of STA–MCA bypass (vs. best medical therapy) on the…

Indications Cavernous malformations are angiographically occult vascular malformations that typically come to clinical attention because of seizures or acute hemorrhage. With widespread use of noninvasive imaging, many cavernous malformations are now being diagnosed incidentally. Surgery is recommended in symptomatic patients with seizures or after at least one symptomatic bleed. In patients with symptomatic brainstem and thalamic cavernous malformations, surgery is usually recommended if the lesion comes…

Additional videos for this topic are available online at . Indications General Indications for Treatment of Dural Arteriovenous Fistulas The indication for treatment of cranial dural arteriovenous fistulas (DAVFs) is dictated by their natural history. Because the risk of hemorrhage and neurologic deficit is directly correlated to the presence of cortical venous reflux (CVR), a general principle is that only these lesions should be treated.…

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Indications Basilar apex aneurysms include ruptured or unruptured basilar bifurcation aneurysms, superior cerebellar artery (SCA) aneurysms, and proximal posterior cerebral artery (PCA) aneurysms. Patients who are young and have good clinical grades (Hunt and Hess grades I to III), broad neck aneurysms, aneurysms with branches originating from side walls, intraluminal thrombus, or significant mass effect from the aneurysm should be considered for microsurgical clipping. Contraindications Patients…

Indications Ruptured aneurysms of the vertebral artery, vertebrobasilar junction, and proximal posterior inferior cerebellar artery (PICA) that are not favorable for endovascular treatment should be considered for surgery. Unruptured aneurysms of the vertebral artery, vertebrobasilar junction, and PICA that are unfavorable for endovascular treatment have a higher 5-year rupture risk compared with anterior circulation aneurysms. Unless the patient has significant medical comorbidities, treatment should be considered.…

Additional videos for this topic are available online at . Indications Distal anterior cerebral artery (DACA) aneurysms are usually small with a relatively broad base, are distally located, and have one or more branches originating from their base. These factors tend to favor clipping over endovascular treatment. When DACA aneurysms rupture, about 50% manifest with frontal intracranial hemorrhage (ICH). The need for ICH evacuation must…

Indications We prefer surgical clipping of most ruptured and unruptured middle cerebral artery (MCA) aneurysms because of the accessibility of their location and the relatively low morbidity and durability of clipping compared with endovascular therapy. The exception is in patients in poor neurologic condition (Hunt and Hess grade IV or V). The decision to treat an unruptured MCA aneurysm is based on an understanding of the…

Additional videos for this topic are available online at . Indications for Craniotomy Ruptured Aneurysm All paraclinoid aneurysms presenting with subarachnoid hemorrhage that are unfavorable for endovascular treatment. Paraclinoid ruptured aneurysms with Hunt and Hess grade I, II, or III presentation and age 50 years or younger. Multiple or bilateral paraclinoid aneurysms, one of which is unfavorable for endovascular treatment in the setting of uncertainty…

Indications Absolute Subarachnoid hemorrhage with intraparenchymal hemorrhage requiring emergent evacuation Subarachnoid hemorrhage with posterior communicating artery (Pcomm) aneurysm not repairable using endovascular techniques Strong Aneurysm presenting with symptoms referable to mass effect, classically presenting as ophthalmoplegia caused by direct compression of the oculomotor nerve Unruptured aneurysm (≥ 7 mm) in a patient 50 years old or younger Aneurysm with intraluminal thrombus Hunt and Hess grade I,…

Indications Absolute Subarachnoid hemorrhage with intraparenchymal hemorrhage requiring emergent evacuation Subarachnoid hemorrhage with anterior communicating artery (Acomm) aneurysm not repairable using endovascular techniques Strong Aneurysm presenting with symptoms referable to mass effect Unruptured aneurysm (≥ 7 mm) in a patient 50 years old or younger Aneurysm with intraluminal thrombus Anterior projecting aneurysm Hunt and Hess grade I, II, or III in a patient 50 years old…

Indications The retrolabyrinthine approach is a hearing-preserving presigmoid approach that uses a mastoidectomy and skeletonization of the sigmoid sinus to expose the presigmoid dura behind the semicircular canals. The principal appeal of this approach is its ability to expose widely the posterior petrous face and cisternal portions of cranial nerves VII and VIII with a minimal degree of cerebellar retraction. The retrolabyrinthine approach additionally is used…

Indications The middle fossa approach is a largely extradural approach to the bony structures that make up the floor of the middle fossa. Although the convex floor of the middle fossa is the most straightforward region to access with this approach, this approach is commonly the starting point for anterior transpetrosal approaches to the internal auditory canal (IAC) or petroclival junction. You’re Reading a Preview Become…

Indications Transsylvian approaches enter the parasellar cisterns on a superior-to-inferior trajectory, forcing the surgeon to work past the carotid artery through the opticocarotid or carotid-oculomotor triangles to access this region, making access of the midbasilar and interpeduncular cisterns difficult. Although the subtemporal approach provides a good view of the basilar artery at the level of the tentorium, it is limited in its rostral visualization, which can…

Indications The suboccipital approach with C1 laminectomy provides adequate visualization of approximately 270 degrees of the circumference around the medulla. This approach does not provide safe access to the 90 degrees anterior to the medulla, however, because the visual angle needed to see this region is obscured by the occipital condyle, which must be drilled in most cases to allow access along this visual trajectory. The…

Indications The unilateral and bilateral subfrontal approaches are the workhorse approaches for access to nearly the entire anterior cranial fossa floor; anterior midline parasellar structures such as the tuberculum sella, anterior communicating artery, and optic chiasm; posterior orbit; and orbital apex. A unilateral subfrontal approach is sufficient for most orbital lesions and midline lesions that are largely eccentric to one side. For large or purely midline…

Indications Frontotemporal craniotomy with orbitozygomatic osteotomy is an adjunct to pterional craniotomy that allows greater rostral trajectory to midline structures. By removing the superior and lateral bony orbit, one gains a more anterior and inferior starting point for the approach than would be possible with a conventional pterional craniotomy. Removal of the zygomatic arch enables inferior displacement of the temporalis muscle, allowing for a lower starting…