Distal Anterior Cerebral Artery Aneurysms: Advantages of Bifrontal Basal Anterior Interhemispheric Approach Over Unilateral Approach

Background: Distal anterior cerebral artery (DACA) aneurysms are uncommon. Most authors have reported technical difficulties because of narrow corridor, reaching the aneurysm and achieving the proximal control during surgery for these aneurysms, and a variety of surgical approaches have been advocated.

Methods: Over a period of 10 years (1999-2010), 132 patients with DACA aneurysms were operated on. Eighty-four of these were operated on through the bifrontal basal anterior interhemispheric approach. Of these 84 patients, 74% were in poor clinical grade (Hunt and Hess grades III-V), and 92.2% had Fisher grade III or IV on computed tomography scan. A surgical trajectory of approximately 2 to 3 cm superior to the anterior cranial fossa floor led directly to the aneurysm. Proximal control was achieved before aneurysm dissection to facilitate parallel clipping.

Results: Good outcomes (Glasgow Outcome Scale V and IV) were seen in 60.2% of the patients, 20.6% had poor outcomes, and 19.1% died. The cause of death in most patients was found to be a poor clinical grade, postoperative infarct, or presence of multiple aneurysms.

Conclusions: The advantages of the bifrontal basal anterior interhemispheric approach are the following: (a) It provided the shortest and most direct trajectory to the aneurysm. (b) Proximal control of the parent A2 vessels could be easily achieved. (c) Release of cerebrospinal fluid from basal cisterns could be done, if necessary. (d) There was minimal distortion of or traction over the aneurysm.