E-ISSN: 1019-5157
ISSN: 2651-5024
Review
Skull Base Surgical Approaches for Microsurgical Clipping of Basilar Apex Aneurysms: A Narrative Review of Anatomical Foundations, Indications, and Surgical Strategy
zhenwei qin ,
Ding Chen ,
beiyan tang ,
Qiang Dong ,
Wei Kang ,
Qiang Liang ,
Yanjiao Jin ,
yawen Pan✉
Department of Neurosurgery, Lanzhou University Second Hospital; Medical Affairs Department, Gansu Rehabilitation Center Hospital; Department of Neurosurgery, The Second Hospital of Lanzhou University; Neurosurgery, Lanzhou University Second Hospital; Key Laboratory of Neurology in Gansu Province, Lanzhou University Second Hospital
Accepted: 27/10/2026
Article in Press
Corresponding Author:
yawen Pan (meiqu1998@163.com)
Abstract
AIM: To synthesize the anatomical rationale, clinical indications, and limitations of skull base approaches for microsurgical clipping of basilar apex aneurysms.
MATERIAL AND METHODS: This narrative review integrates anatomical studies, technical reports, clini-cal series, and comparative literature on anterior, anterolateral, lateral, and combined approaches. Treatment recommendations are considered separately for ruptured and unruptured aneurysms. Anatomical exposure measurements are distinguished from clinical outcomes, and original measurement landmarks are retained.
RESULTS: Approach selection depends on aneurysm neck height and projection, carotid and posterior communicating artery anatomy, perforator relationships, and access for proximal and distal vascular control. Pterional and related anterolateral approaches provide established corridors, whereas orbital or zygomatic extensions can improve access to selected targets. Subtemporal routes favor lateral inspection but can restrict contralateral vascular control. Anterior temporal, transpetrosal, and transcavernous extensions may improve exposure when simpler corridors are inadequate. Endoscopic endonasal access remains an exceptional op-tion supported predominantly by anatomical feasibility studies and limited clinical experience. Additional exposure does not establish lower morbidity, and published height thresholds are not interchangeable across anatomical landmarks.
CONCLUSION: Microsurgical clipping remains complementary to endovascular treatment in carefully se-lected patients. The appropriate approach provides the exposure needed for aneurysm exclusion and perfo-rator preservation while limiting additional tissue manipulation. Current evidence supports individualized planning in experienced multidisciplinary centers but does not establish one universally superior surgical route.
MATERIAL AND METHODS: This narrative review integrates anatomical studies, technical reports, clini-cal series, and comparative literature on anterior, anterolateral, lateral, and combined approaches. Treatment recommendations are considered separately for ruptured and unruptured aneurysms. Anatomical exposure measurements are distinguished from clinical outcomes, and original measurement landmarks are retained.
RESULTS: Approach selection depends on aneurysm neck height and projection, carotid and posterior communicating artery anatomy, perforator relationships, and access for proximal and distal vascular control. Pterional and related anterolateral approaches provide established corridors, whereas orbital or zygomatic extensions can improve access to selected targets. Subtemporal routes favor lateral inspection but can restrict contralateral vascular control. Anterior temporal, transpetrosal, and transcavernous extensions may improve exposure when simpler corridors are inadequate. Endoscopic endonasal access remains an exceptional op-tion supported predominantly by anatomical feasibility studies and limited clinical experience. Additional exposure does not establish lower morbidity, and published height thresholds are not interchangeable across anatomical landmarks.
CONCLUSION: Microsurgical clipping remains complementary to endovascular treatment in carefully se-lected patients. The appropriate approach provides the exposure needed for aneurysm exclusion and perfo-rator preservation while limiting additional tissue manipulation. Current evidence supports individualized planning in experienced multidisciplinary centers but does not establish one universally superior surgical route.
Keywords
Basilar Artery
Intracranial Aneurysm
Microsurgery
Neurosurgical Procedures
Skull Base