Subtemporal approach for distal basilar occlusion for giant aneurysm. Nuances and advantages of the subtemporal approach

We described the subtemporal approach, which was used for distal basilar artery occlusion in a patient with a symptomatic giant unclippable aneurysm. We discuss issues related to positioning and lumbar drainage. We illustrate the basic steps: identification of the tentorial notch; sharp opening of the arachnoid behind the third nerve; placement of a fixed mechanical retractor to "hold" the brain; identification of the third nerve and mobilization from arachnoid attachments; identification of the course and insertion of the fourth nerve; division and retraction of the tentorial edge to enhance exposure; preparation of the "perforator-free zone"; and final clip application followed by ICG fluorescein angiography. We show some of the areas exposed with this approach. The video can be found here: http://youtu.be/S_NLIjKQL_o .