December 22, 2015
This video reviews intraoperative aneurysmal hemorrhage management during clip ligation, an ACoA aneurysm that was exposed through a keyhole, or supraorbital craniotomy, via an eyebrow incision. This is a 52 year old female who presented with an unruptured 10 millimeter incidental ACoA aneurysm. The base of the aneurysm was relatively broad for effective coil embolization or the aneurysm. Microsurgical clip ligation was therefore elected. The aneurism is pointing relatively anteriorly. The minimally invasive supraorbital craniotomies via an eyebrow incision is relatively reasonable for aneurysms that point anteriorly or inferiorly in this region. Let's review the head positioning in this case. The patient's head is turned only minimally. The incision is just above the eyebrow and it's slightly curved posteriorly beyond the edges of the eyebrow. The incision is not made within the eyebrow to decrease the risk of alopecia. Following completion of the incision a left supraorbital craniotomy is performed. I did not remove the rim of the orbit in this case. However, I drilled the edge of the rim all the way flush with the roof of the orbit. The angle of dissection and clip application is often from anterior to posterior, and very much parallel to the roof of the orbit. And additional removal of the rim may not be very beneficial in clip ligation of anteriorly pointing ACoA aneurysms. A lumbar drain was also used at the beginning of the procedure to provide cerebral decompression very early. Here is the drilling of the inferior aspect of the osteotomy. The dura was open in a curvilinear fashion. A rubber dam or a piece of glove was used to slide the carotenoid around the brain in the sub-frontal area. Here's the optic nerve. Here's the optic carotid cisterns. The carotid arteries identified. Additional CSF is drained. The anterior aspect of the Sylvian fissure and more specifically, its medial aspect is also dissected, so that the frontal lobe can be mobilized. Here's the carotid artery optic nerve. Next, A1 is exposed for proximal control. Here's the aneurysm dome. Small amount of gyrus rectus was removed to expose the distal neck of the aneurysm. And a temporary clip was placed across A1 ipsilateral. Here is the contralateral A1. Here's the clip over the ipsilateral A1. The clip is properly across the A1, ipsilaterally. I continue the dissection of the aneurysm. The duma of the aneurism appeared very tense and the turgor of the aneurysm did not seem to be relaxed. However, I believe that the proximal clip ligation was still in place. Even though, as you'll see in a moment, the temporary clip actually came off and I wasn't aware of that at this time. Unfortunately, some bleeding from the superior aspect of the aneurysm was noted. At this point I am still under the impression that temporary occlusion of A1 is instituted. The bleeding is quite brisk and I cannot identify the contralateral A2 to safely apply the permanent clip. First, I attempted to gather the aneurism a little bit with partial coagulation of the sack. So I can see around the bleeding point to identify the proximal A2 contralaterally. This maneuver was not effective. Therefore I placed a tentative clip across the neck to be able to gather the aneurysm just enough so I can see more distal along the neck toward the contralateral side. The tentative clip exposed the exact point of bleeding that you can appreciate here, and also gave me just enough space to be able to see the contralateral A2. Here I'm mobilizing the clip plates posteriorly and upon their closure, you can see the A2 coming into view, just about there. Bleeding was controlled. Here's the contralateral A2. That is patent. The clip is across the entire neck. You can see now that the temporary clip was completely off of the ipsilateral A1. Next, I proceeded with an interoperative fluorescent angiogram, both using fluorescein and ICG. Both methodologies confirm complete exclusion of the aneurysm and patency of both A2s. Here's another view of fluorescein angiography. Here's the funnel's condition of the brain before closure. The dura is approximated. Bone flap was replaced. Postoperative angiogram demonstrated complete exclusion of the aneurism and preservation of the anterior communicating artery complex. An important learning experience from this case is to check and recheck and confirm that the temporary clips are across the parent vessel to the aneurysm if one encounters a tense aneurysm that does not appear to be amenable to manipulation by the dissector. In this case, even though I encountered a tense aneurysm, I persisted upon mobilizing the dome to find a contralateral A2. I should have exercised additional patents and recheck the placement of the temporary clip. As you can see, manipulating a tense aneurysm can lead to intraoperative premature hemorrhage. If such an event occurs it's best to remain composed, use appropriate maneuvers. In this case, a tentative clip to gather the aneurysm and be able to see around the aneurysm so a more definitive clipping is possible. Blind placement of a permanent clip is not recommended and most likely leads to additional injury to the neck of the aneurysm or surrounding branching arteries, as well as perforating vessels. This patient recovered from the anesthesia without any neurological deficits and has done very well from her operation. Thank you.
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