title: Advanced technical skills are required for microsurgical clipping of posterior communicating artery aneurysms in the endovascular era.
abstract: BACKGROUND
  Many neurosurgeons feel competent clipping posterior communicating artery (PCoA) aneurysms and include this lesion in their practice. However, endovascular therapy removes simple aneurysms that would have been easiest to clip with the best results. What remains are aneurysms with complex anatomy and technical challenges that are not well described.
  
  
  OBJECTIVE
  A contemporary surgical series with PCoA aneurysms is reviewed to define the patients, microsurgical techniques, and outcomes in current practice.
  
  
  METHODS
  A total of 218 patients had 218 PCoA aneurysms that were treated microsurgically during an 11-year period. Complexities influencing aneurysm management included (1) large/giant size; (2) fetal posterior cerebral artery; (3) previous coiling; (4) anterior clinoidectomy; (5) adherence of the anterior choroidal artery (AChA); (6) intraoperative aneurysm rupture; (7) complex clipping; and (8) atherosclerotic calcification.
  
  
  RESULTS
  Simple PCoA aneurysms were encountered in 113 patients (51.8%) and complex aneurysms in 105 (48.2%). Adherent AChA (13.8%) and intraoperative rupture (11.5%) were the most common complexities. Simple aneurysms had favorable outcomes in 86.6% of patients, whereas aneurysms with 1 or multiple complexities had favorable outcomes in 78.2% and 75.0%, respectively. Intraoperative rupture (P < .01), large/giant size (P = .04), and complex clipping (P = .05) were associated with increased neurological worsening.
  
  
  CONCLUSIONS
  Because endovascular therapy alters the surgical population, neurosurgeons should recalibrate their expectations with this once straightforward aneurysm. The current mix of PCoA aneurysms requires advanced techniques including clinoidectomy, AChA microdissection, complex clipping, and facility with intraoperative rupture. Microsurgery is recommended for recurrent aneurysms after coiling, complex branches, aneurysms causing oculomotor nerve palsy, multiple aneurysms, and patients with hematomas.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
authors.forename: Nader
authors.initials: N
authors.lastname: Sanai
authors.forename: Nolan
authors.initials: N
authors.lastname: Caldwell
authors.forename: Dario J
authors.initials: DJ
authors.lastname: Englot
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002140:California / Q000453:epidemiology; D057510:Endovascular Procedures / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery*; D008297:Male; D008866:Microsurgery / Q000706:statistics & numerical data*; D008875:Middle Aged; D011361:Professional Competence / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D055815:Young Adult