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The proportion of intracranial aneurysms treated by microsurgical clip ligation has drastically decreased in the endovascular era. However, some aneurysms cannot be treated by current endovascular techniques. Therefore, trainees and young vascular neurosurgeons must develop and maintain microsurgical skills to safely treat aneurysms that require surgery. Ruptured, basilar artery apex, blister-type aneurysms are particularly treacherous and require a high degree of skill to safely manage them surgically. In this video, 2 companion cases are exhibited to demonstrate the nuances of the subtemporal, skull base, approach to the basilar apex region. In each case, the patient consented to surgery and anonymized recording. The subtemporal approach is favored over the trans-sylvian for posteriorly directed basilar apex region aneurysms as the former affords a complete view of the relevant anatomy. Points for consideration include variations on the standard subtemporal approach, use of retractors vs lumbar drainage to mobilize the temporal lobe, and splitting the tentorium vs a suture-retraction technique for visualization of the basilar artery apex region. Techniques for successful navigation of intraoperative rupture are demonstrated. As the number of intracranial aneurysms treated by microsurgery continues to ebb, high-quality educational videos that supplement surgeon experience will become increasingly critical to ensure that a cohort of capable microvascular neurosurgeons is prepared to tackle challenging, but manageable aneurysms, such as the blister-type basilar apex variety. Video (c) Emory University School of Medicine, 2021. Used with permission.

The presented case is of a 65-yr-old gentleman referred for thoracic myelopathy. He developed bilateral, nondermatomal foot dysesthesia 14 mo prior to presentation, which progressed to numbness below the L3 level. He reported progressive gait instability, bilateral lower extremity weakness, and required a cane for ambulation. He subsequently developed urinary incontinence, while bowel function was spared. The neurological examination upon presentation revealed lower extremity strength was reduced to 4/5 in all major muscle groups bilaterally, while sensation and proprioception were reduced below the L3 level. Patellar and Achilles reflexes were not elicited and clonus was absent. Gait was unsteady and slow. The patient was not able to perform heel, toe and tandem gait. MRI revealed abnormal T2 hyper-intense signal and spinal cord expansion from T6 through the conus medullaris. Angiography revealed a dural arteriovenous fistula (dAVF) originating from the left T9 radicomedullary pedicle, which also supplied the Artery of Adamkiewicz (AoA). The patient underwent T8-10 laminectomies. Prior to disconnection of the fistula, an aneurysm clip was applied to the fistulous point and an indocyanine green video angiogram was completed to show that the fistula no longer opacified, but that the AoA remained patent, which was later confirmed with angiography. As of discharge, the patient's motor exam had improved substantially, though his sensory deficits persisted. This case demonstrates that surgical disconnection is requisite in the treatment of spinal dAVF that have a shared blood supply with the AoA, as embolization risks spinal cord infarction. The patient consented to presentation of this case in a de-identified fashion.

The case is of a 49-yr-old female admitted after acute onset lower cervical/upper thoracic region pain with left hemi-body hypoesthesia below the C7 level. Magnetic resonance imaging showed a spinal cord intraparenchymal hemorrhage at the C6/7 levels. Physical exam revealed hypoesthesia on the left from C7 and below with associated 3/5 wrist and finger extensor and 4/5 triceps strength on the left. The remainder of the neurological exam was normal including lower extremity strength and bowel/bladder function. A craniocervical angiogram showed a perimedullary arteriovenous fistula on the left, ventrolateral aspect of the spinal cord with a single feeding artery that originated from the thyrocervical trunk and entered through the left C6 nerve root sleeve. Venous drainage was cephalad to cortical cerebellar veins and to the suboccipital plexus. A branch of the thyrocervical trunk supplying the ventral spinal cord originated close to the fistula, which precluded endovascular embolization. The patient underwent C6-T1 laminectomies for microsurgical treatment of the fistula. This case demonstrates multiple key concepts in the surgical management of these rare lesions as follows: the ventral aspect of the cervical spinal cord can be safely approached from posterior. The venous anatomy is often confusing and intraoperative angiography utilizing both indocyanine green and conventional digital subtraction techniques are of paramount importance. Unlike arteriovenous malformations, the venous drainage can be pruned to gain visualization and trace the venous anatomy retrograde to the point of the fistula. The patient awoke from surgery at her neurological baseline. The patient consented to de-identified publication of this case.