Single-stage "squeeze play" strategy for the clipping of seven aneurysms: illustrative case.

Abstract

Background: Multiple intracranial aneurysms (MIAs) pose complex management challenges due to their elevated cumulative rupture risk and the potential morbidity associated with staged or multimodal treatment. Single-stage microsurgical strategies have been explored to minimize cumulative procedural risk while providing durable aneurysm exclusion. The "squeeze play" technique, dual ipsilateral pterional and interhemispheric craniotomies performed through a single incision, offers a unified corridor for treating aneurysms arising from both sylvian and interhemispheric fissures. Few reports have detailed its use for treatment of multiple aneurysms.

Observations: A woman in her 40s with seven unruptured anterior circulation aneurysms underwent single-stage microsurgical clipping using the squeeze play approach. A right-sided pterional craniotomy allowed successful clipping of the M1-M2, M2-M3, A1, and ophthalmic aneurysms, the latter requiring an anterior clinoidectomy and optic nerve unroofing. A parasagittal interhemispheric craniotomy exposed two pericallosal aneurysms and a callosomarginal aneurysm, all of which were clipped safely. Intraoperative indocyanine green angiography and Doppler ultrasonography confirmed complete aneurysm obliteration with preserved vessel patency. Postoperative CT angiography and digital subtraction angiography demonstrated no residual aneurysms, and the patient was discharged home on postoperative day 3 without neurological deficits.

Lessons: This case highlights the feasibility, efficiency, and safety of microsurgery for comprehensive single-stage treatment of MIAs. Dual ipsilateral craniotomies through a single incision allow definitive clipping of both lateral and midline aneurysms while avoiding the cumulative risks of staged surgeries and the long-term recurrence concerns associated with endovascular therapy. Careful patient selection and meticulous microsurgical technique are essential to achieving optimal outcomes. https://thejns.org/doi/10.3171/CASE25985.