Unilateral Supraorbital Approach to Clip Bilateral Posterior Communicating Artery Aneurysms: 2-Dimensional Operative Video

This video (Video 1) demonstrates bilateral posterior communicating artery (PCoA) aneurysms that were treated through a unilateral supraorbital approach. A 53-year-old woman presented with a Hunt-Hess grade I subarachnoid hemorrhage. Computed tomography scan showed subarachnoid hemorrhage in the left sylvian fissure and basal cistern. Angiography demonstrated bilateral aneurysms of the PCoA. Considering posteromedial projection of the contralateral aneurysm, a unilateral approach from the side of the ruptured aneurysm was chosen to clip bilateral aneurysms. The patient was positioned supine, and the aneurysm was exposed via the left lateral supraorbital approach. We firstly opened the chiasmatic cistern and left carotid cistern, followed by the proximal part of the sylvian fissure. Coagulation of the dura covering the anterior clinoid process and partial clinoidectomy were performed to expose the proximal aneurysm neck. The anterior choroid artery was separated from the distal aneurysm neck. The aneurysm was clipped with a simple straight clip. The interoptic space and contralateral optic carotid space were further dissected to expose the contralateral carotid artery, PCoA, anterior choroid artery, and neck of the aneurysm. A fenestrated clip was used to occlude the aneurysm with preservation of these critical vessels. The patient recovered well without any complications. Postoperative angiography confirmed complete obliteration of these 2 aneurysms. For selected bilateral PCoA aneurysms with non-low-lying and posteromedial projection of the contralateral aneurysm, surgical clipping of all aneurysms via a unilateral approach is a feasible alternative.