The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on supraorbital minicraniotomy for intracranial aneurysm.


Cerebral aneurysms are small balloon-like dilated portions of blood vessels that may occasionally rupture, causing brain haemorrhage, stroke or death. Therapy is then designed to support recovery from the initial bleed, together with specific treatment to prevent re-bleeding.

The majority of cerebral aneurysms arise from the major blood vessels in the centre of the head as they cross the space between the skull and the brain (the subarachnoid space). The standard surgical approach to this area is through an incision in the scalp just in front of the ear and an opening in the underlying bone on the side of the head. The abnormal vessels are approached side-on in the subarachnoid space beneath the brain. The surgical treatment of cerebral aneurysms involves placing a permanent clip across the neck of the aneurysm (effectively closing the neck of the balloon) to separate it from the normal vessel while preserving blood flow to the brain. If clipping is not possible, the aneurysm may be reinforced by wrapping it with synthetic material to reduce the risk of rupture.

Supraorbital minicraniotomy is an alternative approach through a smaller incision made above the eyebrow and through the underlying skull. This allows a front-on approach to the abnormal vessels. The aneurysm is then clipped or wrapped using conventional microsurgical instruments.

Coding recommendations

A code from Y46.- Open approach to contents of cranium or Y47.- Burrhole approach to contents of cranium would be used as a supplementary code following a code from Chapter ‘L’ for the primary intracranial aneurysm surgery carried out.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.