Microsurgical Clip Reconstruction of Multiple Contiguous Aneurysms of the Anterior Communicating Artery Complex: Subfrontal Exposure and Endoscopic Verification—A Case Illustration

BACKGROUND AND IMPORTANCE: Multiple contiguous aneurysms of the anterior communicating artery (ACoA) complex present significant technical challenges due to their irregular geometry and the density of critical hypothalamic perforators. Standard microscopic visualization is often limited by optical obstruction from clip blades or line-of-sight constraints during complex reconstruction. CLINICAL PRESENTATION: A 62-year-old woman presented with aneurysmal subarachnoid hemorrhage. Preoperative digital subtraction angiography and volumetric segmentation identified 4 distinct aneurysmal origins distributed across the ACoA-A2 complex. A subfrontal approach with opening of the proximal sylvian fissure was used to achieve adequate exposure of the aneurysm complex. Stepwise reconstruction was performed using 4 specific clips under intermittent bilateral A1 temporary occlusion. A minor residual neck remnant identified under the microscope was corrected. Endoscopic inspection was subsequently performed for final verification, confirming complete aneurysm obliteration and preservation of the deep perforating arteries. The patient was discharged with a modified Rankin Scale score of 0. Three-month follow-up digital subtraction angiography demonstrated complete angiographic occlusion. CONCLUSION: For multiple contiguous ACoA aneurysms, a systematic multimodal verification strategy incorporating subfrontal exposure with opening of the proximal sylvian fissure and endoscopic inspection may help ensure complete exclusion while protecting the hypothalamic circulation.