Indications
Absolute
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Subarachnoid hemorrhage with intraparenchymal hemorrhage requiring emergent evacuation
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Subarachnoid hemorrhage with posterior communicating artery (Pcomm) aneurysm not repairable by endovascular coiling
Strong
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Large aneurysm (≥10 mm)
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Unruptured aneurysm (≥7 mm) in a patient 50 years old or younger
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Aneurysm with intraluminal thrombus
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Anterior projecting aneurysm
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Hunt and Hess grade I, II, or III in a patient 50 years old or younger
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Neurologic symptoms, classically manifesting as ophthalmoplegia owing to direct compression of the oculomotor nerve from the aneurysm
Contraindications
Strong
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Aneurysm with significant calcification or atheroma
Relative
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Hunt and Hess grade IV or V with aneurysm repairable by endovascular coiling
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Subarachnoid hemorrhage with aneurysm repairable by coiling in a patient older than 60 years
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Unruptured aneurysm less than 7 mm in a patient older than 70 years
Planning and positioning
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The approach is chosen based on the location of the aneurysm.
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Placement of an external ventricular drain or lumbar drain during the preoperative period for cerebrospinal fluid drainage is frequently advantageous.
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A radiolucent head holder should be used in case intraoperative angiography is performed.
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Proper head positioning helps to minimize brain retraction.
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Antibiotic prophylaxis should be administered before skin incision.
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Mannitol given at the time of skin incision also helps with brain relaxation.
