====== Multiple intracranial aneurysm treatment ======

A combination of surgical operation and endovascular treatment, as well as simple surgical treatment, has been recommended for [[Multiple intracranial aneurysm]] treatment
((Chung J, Shin YS: Multiple intracranial aneurysms treated by multiple treatment modalities. Neurosurgery 69: E1030- 1032, 2011))
((James Ling A, D’Urso PS, Madan A: Simultaneous microsurgical and endovascular management of multiple cerebral aneurysms in acute subarachnoid haemorrhage. Clin Neurosci 13: 784-788, 2006)).

Correct localization of the rupture aneurysm based on a comprehensive diagnosis is key to MIA treatment.

The decision regarding the type of surgery to be used (either one-stage or multiple-stage surgery) as an operation strategy for multiple aneurysms and the location of bilateral multiple aneurysms (either along the bilateral approach or the unilateral approach) are still not clearly elucidated. 
 
All the aneurysms should be treated in one session whenever possible to protect the patient from rebleeding
((Wang G, Feng WF, Zhang GZ, Li WG, Li MZ, He XY, Peng SW, Qi ST. [Diagnosis and
treatment of multiple intracranial aneurysms]. Nan Fang Yi Ke Da Xue Xue Bao.
2015 Jan;35(1):121-4. Chinese. PubMed PMID: 25613624.
)).

Single-stage coil embolization of multiple unruptured intracranial aneurysms is technically feasible. The time required for such procedures and the rate of complications observed seem acceptable
((Cho YD, Ahn JH, Jung SC, Kim CH, Cho WS, Kang HS, Kim JE, Han MH. Single-Stage
Coil Embolization of Multiple Intracranial Aneurysms: Technical Feasibility and
Clinical Outcomes. Clin Neuroradiol. 2014 Dec 17. [Epub ahead of print] PubMed
PMID: 25516149.))
((Shen X, Xu T, Ding X, Wang W, Liu Z, Qin H. Multiple intracranial aneurysms:
endovascular treatment and complications. Interv Neuroradiol. 2014
Jul-Aug;20(4):442-7. doi: 10.15274/NRJ-2014-10037. Epub 2014 Aug 28. PubMed PMID:
25207907; PubMed Central PMCID: PMC4187440.)).

Although a number of reports are available on occlusion of bilateral aneurysms in the middle cerebral artery bifurcation along with the unilateral approach
((Hopf NJ, Stadie A, Reisch R: Surgical management of bilateral middle cerebral artery aneurysms via a unilateral supraorbital key-hole craniotomy. Minim Invasive Neurosurg 52: 126-131, 2009))
((Martellotta N, Gigante N, Toscano S, Maddalena GF, Tripodi M, Settembrini G,Stroscio C, Distefano G, Citro E: Unilateral supraorbital keyhole approach in patients with middle cerebral artery (M1-M2 segment) symmetrical aneurysms. Minim Invasive Neurosurg 46: 228-230, 2003))
, according to Oshiro’s study 
((Oshiro EM, Rini DA, Tamargo RJ: Contralateral approaches to bilateral cerebral aneurysms: A microsurgical anatomical study. J Neurosurg 87: 163-169, 1997))
, contralateral middle cerebral artery bifurcation is difficult to observe along the unilateral pterional approach when the contralateral M1 segment is >14 mm.
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Careful preoperative planning for patients with multiple intracranial aneurysms is paramount given the importance of an appropriate trajectory and exposure for each aneurysm that will be clipped. The general principle is to clip aneurysms in a retrograde manner, such that more distal aneurysms are clipped earlier, and more superficial aneurysms are clipped later. 

===== Case reports =====
A patient had an [[unruptured middle cerebral artery aneurysm]] and [[basilar apex aneurysm]]s and elected for surgical [[clipping]] of both lesions. An [[orbitozygomatic]] craniotomy ipsilateral to the MCA aneurysm was performed to permit the clipping of both lesions. The dissection initially focused on exposure of the [[middle cerebral artery aneurysm]] and then focused on the carotid-oculomotor triangle to permit basilar apex exposure and aneurysm clipping. The MCA aneurysm was clipped second. Postoperative imaging demonstrated complete obliteration of both aneurysms. The patient gave [[informed consent]] for surgery and [[video]] recording. [[Institutional review board]] approval was deemed unnecessary
((Hendricks BK, Spetzler RF. Clipping of Basilar and Middle Cerebral Artery
Aneurysms: 2-dimensional operative video. Oper Neurosurg (Hagerstown). 2020 May
4. pii: opaa116. doi: 10.1093/ons/opaa116. [Epub ahead of print] PubMed PMID:
32365193.
)).

===== References =====