Single-Stage Bilateral Microsurgical Treatment of Five Complex Unruptured Anterior Circulation Aneurysms Assisted by Rapid Ventricular Pacing: Case Report and Literature Review

Background: Single-stage bilateral microsurgical treatment of multiple anterior circulation aneurysms is uncommon and increases operative complexity. Rapid ventricular pacing (RVP) produces brief, reversible, and titratable systemic hypotension that can facilitate clip reconstruction when prolonged temporary occlusion is undesirable or insufficient. Case Description: A 54-year-old woman with untreated hypertension and active smoking presented with a pupil-involving left oculomotor nerve palsy and was found to have five unruptured anterior circulation aneurysms: on the left, a paraclinoid internal carotid artery (ICA) aneurysm (Barami type IIIa) and a posterior communicating artery (PCoA) aneurysm; on the right, an ICA C6 blood blister–like lesion, a PCoA aneurysm, and a middle cerebral artery (MCA) M1 pre-bifurcation aneurysm. She underwent sequential left and right mini-pterional craniotomies in a single operative session with bilateral extradural and intradural anterior clinoidectomies. The paraclinoid aneurysm was reconstructed with a 90° fenestrated clip reinforced with a microclip, both PCoA aneurysms were clipped, the blister-like lesion was treated with focal bipolar coagulation under temporary ICA occlusion, and the MCA aneurysm was reconstructed with a straight clip plus a semicurved microclip. RVP was applied in 12 episodes (19 s to 1 min 40 s; 180 bpm) during key reconstruction steps, without arrhythmia requiring intervention or postoperative troponin elevation. Immediate and approximately 2-month postoperative computed tomography angiography (CTA) demonstrated complete aneurysm occlusion. The preoperative left oculomotor nerve palsy persisted, and the modified Rankin Scale (mRS) score was 2 at discharge and at 2-month follow-up. Conclusion: In this carefully selected patient, single-stage bilateral microsurgery supported by repeated RVP was feasible for the definitive treatment of five complex aneurysms, although persistent cranial neuropathy was observed. The advantages of a single session must be weighed against longer operative time and the morbidity of bilateral craniotomies, and the evidence supporting RVP remains limited to small, noncomparative series. Keywords: rapid ventricular pacing, microsurgical clipping, unruptured intracranial aneurysm, multiple intracranial aneurysms, blood blister–like aneurysm