case_images: PMC4857316_01
case_images: Computed tomography (CT) on admission showing subarachnoid hemorrhage.
case_images: 10.1177_2050313X15578318-fig1.jpg
case_images: PMC4857316_01_10.1177_2050313X15578318-fig1.jpg
case_images: fig1-2050313X15578318
case_images: Coma Scale and Hunt and Hess grading of 13 and 3 with World Federation of Neurosurgical Societies (WFNS) grade 2. Computed tomography (CT) demonstrated subarachnoid hemorrhage (Figure 1), and three-dimensional computed tomographic angiography (3DCTA) demonstrated an aneurysm, which was 4 mm in diameter at the tip of the basilar artery.
case_images: (Left) Three-dimensional computed tomographic angiography (3DCTA) showing an aneurysm at the tip of basilar artery. (Right) CT showing the distance (22 mm) between the tip of posterior clinoid process and aneurysmal neck.
case_images: 10.1177_2050313X15578318-fig2.jpg
case_images: PMC4857316_01_10.1177_2050313X15578318-fig2.jpg
case_images: fig2-2050313X15578318
case_images: The height from the posterior clinoid process to the aneurysm was 22 mm (Figure 2).
case_images: (Left) Three-dimensional computed tomographic angiography (3DCTA) (posterior view) showing the origin of right vertebral artery narrow and curved. (Right) Digital subtraction angiography showing crooked left vertebral artery.
case_images: 10.1177_2050313X15578318-fig3.jpg
case_images: PMC4857316_01_10.1177_2050313X15578318-fig3.jpg
case_images: fig3-2050313X15578318
case_images: When endovascular surgery was first attempted, the microcatheter could not reach the aneurysm because of a crooked vertebral artery (Figure 3).
case_images: Sagittal view of magnetic resonance imaging (MRI) showing the basilar apex aneurysm pushing up the third ventricle floor (arrow).
case_images: 10.1177_2050313X15578318-fig4.jpg
case_images: PMC4857316_01_10.1177_2050313X15578318-fig4.jpg
case_images: fig4-2050313X15578318
case_images: We adopted the trans-lamina terminalis and trans-third ventricle approach, after confirming the pathway to the basilar tip aneurysm on a sagittal view with a magnetic resonance imaging (MRI) (Figure 4).
case_images: Intraoperative photographs. (Left) Opened lamina terminalis (arrow) and bilateral A1. (Right) The sclerosed yellow basilar artery (BA) with temporary clip (arrow head) and aneurysmal neck (arrow) at the back of opened third ventricle floor.
case_images: 10.1177_2050313X15578318-fig5.jpg
case_images: PMC4857316_01_10.1177_2050313X15578318-fig5.jpg
case_images: fig5-2050313X15578318
case_images: We confirmed the position of the floor of the third ventricle and also the mesencephalic aqueduct behind the opened lamina terminalis (Figure 5, left). On opening the floor of the third ventricle, we could confirm the sclerosed yellow basilar artery and the basilar tip aneurysm (Figure 5, right).
case_images: Postoperative temperature chart.
case_images: 10.1177_2050313X15578318-fig6.jpg
case_images: PMC4857316_01_10.1177_2050313X15578318-fig6.jpg
case_images: fig6-2050313X15578318
case_images: The patient's level of consciousness gradually improved after the procedure; however, hypothermia persisted to day 6 post-surgery (Figure 6).
case_images: Postoperative 3DCTA showed the absence of aneurysm.
case_images: 10.1177_2050313X15578318-fig7.jpg
case_images: PMC4857316_01_10.1177_2050313X15578318-fig7.jpg
case_images: fig7-2050313X15578318
case_images: We warmed the patient with an electric blanket for 3 consecutive days. 3DCTA did not show cerebral vasospasm, and we confirmed that the aneurysm was absent on the sixth postoperative day (Figure 7).