• Hugo Andrade-Barazarte, Juri Kivelev, Felix Goehre, Behnam Rezai Jahromi, Kosumo Noda, Tarik F Ibrahim, Riku Kivisaari, Hanna Lehto, Mika Niemela, Juha E Jääskeläinen, and Juha A Hernesniemi.
• *Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; ‡Department of Neurosurgery, University Central Hospital Antonio Maria Pineda, Barquisimeto, Venezuela; §Department of Neurosurgery, Stroke Center, Bergmannstrost Hospital, Halle, Germany; ¶Department of Neurosurgery, Stroke Center, Teishinkai Hospital, Sapporo, Japan; ‖Department of Neurosurgery, Loyola University Medical Center, Maywood, Illinois; #Department of Neurosurgery, Kuopio University Central Hospital, Kuopio, Finland.
• Neurosurgery. 2015 Dec 1; 77 (6): 916-26; discussion 926.

BackgroundBilateral aneurysms located between the 2 middle cerebral artery (MCA) bifurcations may be approachable through a single unilateral approach.ObjectiveTo identify anatomic parameters based on imaging that would favor a contralateral approach.MethodsFrom January 1998 to December 2013, we retrospectively identified 173 patients with bilateral intracranial aneurysms. Fifty-one patients had bilateral MCA aneurysms. A total of 38 patients underwent a single craniotomy with a contralateral microsurgical approach (group 1 or contralateral group) and 13 patients underwent bilateral craniotomies (group 2 or bilateral group). For both groups, we analyzed aneurysm characteristics, morphology, size, projections, and distance to the contralateral corridor, as well as surgical time, outcome, and postoperative complications.ResultsAll aneurysms approached contralaterally were unruptured and without wall calcifications. Of the contralaterally approached aneurysms, 97% were smaller than 14 mm. The median length of the contralateral A1 was 13.2 mm (range: 6-19.8 mm) and the median length of the contralateral M1 was 14.2 mm (range: 4.6-21 mm). The contralateral group had a good postoperative outcome (modified Rankin Scale 0-3) in 80% of ruptured cases and 86% of unruptured cases. The median surgical time was 120 minutes (range: 75-255 minutes), 43% shorter than the bilateral group.ConclusionThe contralateral approach for bilateral MCA aneurysms in selected patients is feasible in experienced hands, with acceptable morbidity and mortality. The contralateral approach requires a meticulous preoperative analysis of the characteristics of the aneurysms to be clipped and of the anatomic constraints of the microsurgical operative corridor.AbbreviationsA1, anterior cerebral artery proximal segmentbMCA, bilateral middle cerebral arteryCTA, computed tomographic angiographyHH, Hunt-Hess scaleIA, intracranial aneurysmsICA, internal carotid arteryICAbif, internal carotid artery bifurcationMCA, middle cerebral arteryM1, middle cerebral artery proximal segmentmRS, modified Rankin ScaleSAH, subarachnoid hemorrhage.

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