**5.1 Positioning**

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

The purpose of active treatment for UIAs is to permanently and safely occlude the aneurysmal lumen while preserving the normal cerebral vasculature. In order to achieve this, two types of approaches have been conceived: surgical (via craniotomy), which includes clipping and bypass procedures, or endovascular. As certain lesions cannot be safely and efficiently removed from arterial circulation either by clipping or by endovascular procedures, bypass surgery has been elaborated to remove the aneurysm and its parent vessel, without sacrificing arterial supply to the involved tissues. Currently, there are no controlled randomized studies that single out the superior form of treatment for UIAs. Optimal treatment should focus on the following

*Multiannual incidence of aneurysmal rupture, as hospitalized and surgically treated in our institution between* 

Since the majority of studies in the reported literature are retrospective in nature, they may suffer from bias. As of yet, the best sources of information regarding the outcome of UIA treatment originate from comparative studies between natural history and complication rates of certain therapies [60]. As our surgical experience exceeds that of endovascular procedures, as well as our standing concerning its importance in the prevention of rupture, we will exclusively present the

Although seemingly easy in theory, placing a clip at the neck of the aneurysm (i.e., its point of origin) represents a genuine surgical challenge because of the need

technical breakdown of aneurysm clipping, according to our practice.

**152**

aspects:

**Figure 1.**

**4. Treatment strategies**

*January and December 2017.*

• Age and clinical features of the patient

• Technical capabilities of the facility

• Anatomy, size, and location of the aneurysm

**5. Aneurysm clipping: technical breakdown**

• Institutional and personal experience in a certain field

This is a crucial stage that can either facilitate or hinder the surgical intervention. The patient is placed in a dorsal decubitus. The patient's head should be positioned so that the planned craniotomy is easy to perform, while ensuring that there is no substantial jugular compression (i.e., if the head is rotated excessively to one side) or that proper ventilation is not impeded (i.e., much too little distance between the tip of the mandible and the sternum). The head can be immobilized by a headholder, if this does not hamper venous drainage. We recommend shaving the head, or at the very least the area around the incision, to minimize the risk of infection. Using cutaneous antiseptics such as iodine solution or chlorhexidine, the skin must be thoroughly cleansed, with special attention toward the auricle and the external ear canal.
