A pterional approach is the most common for aneurysm surgery, not only for anterior circulation aneurysms but also for basilar tip aneurysms.
2. subfrontal approach: especially useful for aneurysms pointing superiorly when there is a large amount of frontal blood clot (allows clot removal during approach)
The surgical approach may be difficult because of the complex arterial relationship, perforator preservation, frequent association between aneurysms and AcoA anomaly, and the potential for cognitive dysfunction.
Posterior and superior projections are the most complex to deal with because of the difficult dissection of the perforators and the contralateral A2, respectively. Approaching from the side of the dominant A1 ensures a prompt proximal control. Searching preoperatively for an eventual rotation of the AComA complex and for the location of the A2s can be very helpful for intraoperative orientation 3).