Trans-lateral ventricular approach for surgical treatment of high-located P2–P3 junction posterior cerebral artery aneurysms: from anatomical research to clinical application

Background: Posterior cerebral artery (PCA) aneurysms, though rare, pose treatment challenges. Endovascular therapy is the preferred option, but microsurgery becomes necessary in certain cases. Various microsurgical approaches have been suggested for PCA aneurysms, particularly those at the P2–P3 junction. This study highlights the trans-lateral ventricular approach (TVA) for addressing these complex aneurysms. This study aims to assess the feasibility and safety of the trans-lateral ventricular approach (TVA) for treating high-located complex PCA aneurysms at the P2–P3 junction. The study evaluates both clinical outcomes and anatomical considerations. Methods: Two cases of PCA aneurysms at the P2–P3 junction were treated using TVA in 2019. Navigation-guided entry via the interparietal sulcus was planned. Ventriculostomy was performed from the cortex to the lateral ventricle’s atrium. Medial atrial floor dissection exposed PCA’s P2–P3 segments. Neuronavigation and ultrasound-aided guidance was used. Anatomical studies on fixed and contrast-perfused specimens refined the approach. Results: Both cases saw successful aneurysm clipping. The unruptured aneurysm patient was discharged in 6 days. The poor-grade SAH patient required extended ICU care, moving to rehabilitation with mRS = 4. The unruptured complex aneurysm case exhibited no deficits, returning to work in 3 months. Anatomical dissections validated TVA for high-located P2–P3 junction PCA aneurysms. Conclusion: While endovascular therapy remains primary, this study demonstrates the viability of navigation-guided TVA for select high-located P2–P3 junction PCA aneurysms. Successes and challenges underscore the importance of patient selection and anatomical awareness.