Basilar Artery Aneurysms

Dr Bernardo is exceptionally experienced in the surgical treatment of basilar artery aneurysms, having operated on an extraordinary number of cases worldwide and frequently being called upon to manage the most complex and challenging presentations.

“When operating on basilar artery aneurysms, time freezes. Life rests in the surgeon’s hands—shaped by depth of training, steadied by resolve, and guided by the wisdom to choose rightly when no margin remains. In that suspended moment, healing or silence is decided, and mastery is the courage to choose without regret.”

Basilar artery aneurysm surgery represents one of the most demanding frontiers in cerebrovascular and skull base surgery. These aneurysms arise deep within the brain, at the very center of vital neurological function, where the basilar artery supplies the brainstem, thalami, cerebellum, and the delicate perforating vessels essential for consciousness, respiration, and motor control. Every surgical maneuver occurs within a confined and unforgiving space, where millimeters separate durable cure from irreversible neurological injury. For this reason, basilar artery aneurysm surgery is never routine; it is an individualized, highly deliberate intervention that requires exceptional technical mastery, profound anatomical understanding, and disciplined judgment refined over years of focused practice.

The management of basilar artery aneurysms must be tailored precisely to the aneurysm’s location, morphology, size, projection, and relationship to surrounding perforators and cranial nerves. Aneurysms may arise at the basilar apex, along the basilar trunk, or at the vertebrobasilar junction, each presenting distinct anatomical and surgical challenges. No single approach is universally applicable. Instead, the surgeon must command a wide spectrum of microsurgical and skull base approaches, selecting the strategy that provides optimal exposure, proximal and distal vascular control, and maximal preservation of neurological function.

For basilar apex aneurysms, variations of the pterional and extended orbitozygomatic approaches are commonly employed, often combined with extensive skull base bone removal to minimize brain retraction and widen the surgical corridor through the interpeduncular cistern. Subtemporal approaches may be used for laterally or anterolateral projecting lesions but require careful handling of the temporal lobe and venous drainage. 

For aneurysms of the basilar trunk, surgical exposure is often even more complex.. In more challenging cases, a combined subtemporal conservative posterior transpetrosal transtentorial approach may be necessary. This approach incorporates selective petrous bone removal and tentorial incision to expand the operative corridor, allowing safe visualization of the basilar trunk while preserving venous structures and minimizing temporal lobe retraction. In selected cases, when the aneurysm of the basilar trunk is projecting laterally, a transcavernous extension may be required, allowing further mobilization of the internal carotid artery and cranial nerves within the cavernous sinus to improve access and visualization of high-riding or posteriorly projecting aneurysms. Mastery of transcavernous techniques demands detailed knowledge of cavernous sinus anatomy and meticulous microsurgical skill, as the margin for error in this region is exceedingly narrow. When executed properly, this skull base strategy provides controlled access to the aneurysm and its perforators, while respecting the surrounding neurovascular anatomy.

For aneurysms located at the lower basilar trunk or vertebrobasilar junction, far-lateral, transcondylar, or extended retrosigmoid approaches may be required. These approaches involve complex skull base drilling and demand intimate familiarity with the lower cranial nerves, vertebral artery anatomy, and brainstem perforators. In selected situations, combined or staged approaches are necessary, reinforcing the principle that anatomy—not habit or preference—must dictate the surgical plan.

Fundamental skull base surgery principles underpin all successful basilar artery aneurysm surgery. These include prioritizing bone removal over brain retraction, wide cisternal opening for cerebrospinal fluid release, early identification of neurovascular landmarks, and precise microsurgical dissection under high magnification. The objective is not merely to reach the aneurysm, but to do so with full vascular control, clear visualization of perforators, and the ability to apply clips with absolute precision. Achieving this level of proficiency requires prolonged, meticulous training, extensive laboratory dissection, and sustained exposure to complex clinical cases.

Equally critical to technical skill is the surgeon’s ability to understand what must be done in each specific circumstance—and, just as importantly, what should not be done. Basilar artery aneurysm surgery demands constant intraoperative reassessment. Initial plans may need to be adapted in response to fragile vessel walls, unexpected perforators, or limitations in exposure. This adaptability reflects not improvisation, but deep anatomical knowledge and intellectual discipline.

At the heart of this field lies profound intellectual honesty. Not every basilar artery aneurysm should be treated surgically, and not every aneurysm should be treated by the same surgeon. Choosing the right solution for the patient requires a clear and honest appraisal of one’s experience, technical capabilities, and limitations. True professionalism means recognizing when microsurgical clipping offers the best chance of durable cure, when endovascular strategies may be safer, and when referral or collaboration is in the patient’s best interest. This honesty is not a concession—it is a defining element of mastery.

Ultimately, basilar artery aneurysm surgery is a convergence of art, science, and ethics. It demands meticulous training, disciplined judgment, and the humility to balance ambition with restraint. The highest standard of care is achieved not through technical bravado, but through thoughtful decision-making grounded in experience, self-awareness, and an unwavering commitment to do what is right for each individual patient.