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ACoA Aneurysm Clipping: Retractorless Surgery

January 28, 2016


The procedure illustrated here, emphasize the importance of using the microsurgical instruments as the tools of dynamic retraction over the fixed retractor blades to mobilize the brain and expose the lesion. Here's a 62-year-old female who presented with an unruptured 8 millimeter Anterior Communicating Artery Aneurysm, more specifically in this case, the aneurysm is more cranially located and has a wider distance against or away from the floor of the anterior cranial fossa, you can see them morphology of the aneurysm, one of the A2s is wrapping around the neck. And here's another view of the aneurysm neck, which is very broad base, including the anterior communicating artery complex. So especially in this case, because this aneurysm is maintaining a wider distance away from the middle fossa, aggressive retraction of the frontal lobe or removal of the gyrus rectus may be necessary to remove the tumor. However, if dynamic retraction is used efficiently, only the part of the pathology that is at every moment necessary during this surgery can be exposed with minimal transgression or retraction of the surrounding neurovascular structures. Standard curvilinear incision in the left front temporal craniotomy was done, anterior limb of the psyllium fisher was dissected to see the optic nerve, wide dissection of the arachnoid bands mobilizes the frontal lobe based on gravity retraction. The A1 and A2 branches are evident, you can see the neck of the aneurysm, ipsilateral A2, here's the perforator beneath the neck of aneurysm over the chiasm, temporary clip was placed on left A1, the aneurysm was better defined. Straight finished clip was used to collapse the distal neck of the aneurysm, all the perforators were carefully protected. A second straight clip, a fenestrated one was used to collapse the more proximal neck of the aneurysm while fenestrating the ipsilateral A2. This clip configuration especially effective for closure of the neck of the aneurysm that involve the ACoA complex. Can see the use of dynamic retraction and the suction device. Only the very small part of the anatomy that is being investigated or inspected is exposed. The use of the fixed retractor blades can actually interfere with clear exposure of the very deep operative corridors as the thick or wide fix retractor blades do not provide significant control over the vector of the retraction. Here you can see the clip blades are across the entire neck of the aneurysm. Minimal amount of gyrus rectus was removed. Interoperative Fluorescein Angiography reveals complete exclusion of the aneurysm. This patient recovered from her surgery without any untoward effect. Again, this video emphasizes the importance and the utility of dynamic retraction to reach lesions that are hidden by the overline in normal brain. Thank you.

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