title: The endonasal approach for treatment of cerebral aneurysms: A critical review of the literature.
abstract: The last two decades of neurosurgery have seen flourishing use of the endonasal approach for the treatment of skull base tumors. Safe and effective resections of neoplasms requiring intracranial arterial dissection have been performed using this technique. Recently, there have been a growing number of case reports describing the use of the endonasal approach to surgically clip cerebral aneurysms. We review the use of these approaches in intracranial aneurysm clipping and analyze its advantages, limitations, and consider future directions. Three major electronic databases were queried using relevant search terms. Pertinent case studies of unruptured and ruptured aneurysms were considered. Data from included studies were analyzed. 8 case studies describing 9 aneurysms (4 ruptured and 5 unruptured) treated by the endonasal approach met inclusion criteria. All studies note the ability to gain proximal and distal control and successful aneurysm obliteration was obtained for 8 of 9 aneurysms. 1 intraoperative rupture occurred and was controlled, and delayed complications of cerebrospinal fluid leak, vasospasm, and hydrocephalus occurred in 1, 1, and 2 patients, respectively. Described limitations of this technique include aneurysm orientation and location, the need for lower profile technology, and challenges with handling intraoperative rupture. The endonasal approach for clipping of intracranial aneurysms can be an effective approach in only very select cases as demonstrated clinically and through cadaveric exploration. Further investigation with lower profile clip technology and additional studies need to be performed. Options of alternative therapy, limitations of this approach, and team experience must first be considered.
authors.affiliation: Department of Neurological Surgery, Loyola University School of Medicine, Maywood, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Heiferman
authors.affiliation: Department of Neurological Surgery, Loyola University School of Medicine, Maywood, USA.
authors.forename: Aravind
authors.initials: A
authors.lastname: Somasundaram
authors.affiliation: Edward Hines, Jr. VA Medical Center, Hines, USA.
authors.forename: Alexis J
authors.initials: AJ
authors.lastname: Alvarado
authors.affiliation: Department of Otolaryngology, University of North Carolina School of Medicine, Chapel Hill, USA.
authors.forename: Adam M
authors.initials: AM
authors.lastname: Zanation
authors.affiliation: Department of Otolaryngology, Loyola University School of Medicine, Maywood, USA.
authors.forename: Amy L
authors.initials: AL
authors.lastname: Pittman
authors.affiliation: Department of Neurological Surgery, Loyola University School of Medicine, Maywood, USA; Edward Hines, Jr. VA Medical Center, Hines, USA. Electronic address: agermanwala@gmail.com.
authors.forename: Anand V
authors.initials: AV
authors.lastname: Germanwala
mesh_terms: D017542:Aneurysm, Ruptured / Q000601:surgery*; D065634:Cerebrospinal Fluid Leak; D006801:Humans; D006849:Hydrocephalus; D002532:Intracranial Aneurysm / Q000601:surgery*; D057605:Natural Orifice Endoscopic Surgery; D044583:Neuroendoscopy / Q000379:methods*; D009666:Nose; D011183:Postoperative Complications; D013525:Surgical Instruments; D020301:Vasospasm, Intracranial
keywords: Cerebral aneurysm; Clipping; Endonasal; Endoscopic