Introduction: Aneurysms located at the middle cerebral artery bifurcation remain a clear neurosurgical indication. We detail here the steps necessary to enable safe surgery for Sylvian fissure aneurysms.
Methods: An angiogram with 3D reconstruction is obtained and reviewed intraoperatively, just prior to the skin incision. During the exposure, the cistern is kept open by small cottonoids, thereby avoiding brain retraction. Continuous monitoring of MEPs along with ICG microscopic angio-fluorescence allows for detection of vascular compromise. Intraoperative angiography with 3D reconstruction allows for immediate correction of less than satisfactory surgical outcome.
Conclusions: Careful planning of surgical strategy followed by a minimally invasive technique (with continuous neuro-monitoring) ensures safe surgery. The availability of intra-operative radiological guidance allows for optimal management.