An operative approach to aneurysms located at the lower half of the basilar artery or the vertebro-basilar junction is difficult. The transoral transclival approach, developed by Sano et al., seems to be reasonable, but it has been used in only a few cases. The most serious problem with this approach lies in high incidence of postoperative complications involving formation of a CSF fistula communicating with the nasopharyngeal cavity and the consequent meningitis.
This approach was used in three cases of basilar artery-anterior inferior cerebellar artery aneurysms. Aneurysmal neck clipping was carried out in all three cases. The first patient, on whom an emergency operation was performed in a critical condition immediately after the re-rupture of a basilar aneurysm, died 4 days after the operation without signs of recovery. In the second case, CSF fistula formation and the consequent fungal meningitis took place in the postoperative course, but the patient was discharged without any neurological deficit. The result of the third patient was satisfactory and no complication occurred postoperatively.
Based on this experience, the importance of complete closure of the nasopharyngeal mucosa and usefulness of long-term nasopharyngeal packing and of continuous spinal drainage were described.