The possible causes of postoperative brain damage were examined in 100 cases of cerebral aneurysms operated on by the pterional approach. Postoperative brain damage occurred in 15% of cases, located mostly in the inferior frontal lobe. Its incidence was higher in early than in delayed operation and increased with severity of preoperative clinical conditions but not correlated with patient age and aneurysm location. The venous perfusion patterns in the inferior frontal lobe were classified into three types based on preoperative venograms: Sylvian type drained mainly into the superficial Sylvian veins (SSVs), Frontal type drained mainly into the frontal bridging veins, and Intermediate type. Postoperative brain damage was most frequent in the Sylvian type with statistical significance (p < 0.01). The brain retraction procedure impairs regional cerebral blood flow (rCBF). Venous congestion in the retracted inferior frontal lobe, caused by stretching and narrowing of SSVs due to both brain retraction and dissection of the Sylvian fissure, also reduces rCBF. Thus, a marked reduction in rCBF in the retracted area causes postoperative brain damage. Postoperative venograms showed the SSVs to be obscured in 24% of patients, indicating that the pterional approach possibly influences the SSV perfusion. A venous perfusion disorder during the pterional approach is the most important factor in postoperative brain damage, and careful preoperative assessment of cerebral veins is indispensable.