January 20, 2016
Management of intraoperative aneurysmal hemorrhage without proximal control can be quite daunting in the face of torrential bleeding. Let's review the operative events for a case of a 44 year-old female who presented with subarachnoid hemorrhage from an eight millimeter right-sided MCA aneurysm. You can see the location of the aneurysm pointing inferiorly and somewhat anteriorly, very closely related to the dura along the anterior aspect of the temporal lobe. Obviously, the dome can be adherent to the dura and any manipulation in the area should consider avoidance of any traction on the dome leading to premature rupture. A right-sided frontotemporal craniotomy was completed. A Sylvian fissure was generously dissected. One of my residents was working at the time of dissection, and unfortunately, intraoperative bleeding was encountered due to manipulation of a temporary clip that was placed distal to the aneurysm since the vascular architecture was misunderstood. Here's the dissection in this area. As you can see, we're relatively superficial in the Sylvian fissure and this aneurysm is more deep. The bifurcation of M2 branches can be misleading and lead someone to believe that they are at the level of the bifurcation even though in fact, they are more distal here. You can see a temporary clip was attempted to place across the one of the M2 branches instead of the M1 and therefore, hemodynamic changes within the dome led to premature bleeding. At this time, I took over and inspected the operative field and additional suction was used via my assistant to clear the operative field. The bleeding is not very torrential at this time at least. I continue to follow the flow of the blood so that I can find the exact source of bleeding. I suspect that the dome most likely facing anteriorly has ruptured, and I'm hoping that I can find any structure that can potentially look like the sac so a temporary clip can be placed across the sac tentatively to control the bleeding and allow further microsurgical dissection. Here you can see the M2 branches, the bleeding obviously originates deeper than these two M2 trunks. I continued to follow the flow of the blood. I remained patient. As long as the bleeding is not significant, I continue to continue the dissection. I could have used adenosine to induce temporary cardiac arrest and work within a clearer operative field. However, I felt the bleeding is not necessarily that bothersome and I continued working through the area, trying to find the bleeding source. This part of the video has been not edited so that the operative events during this crucial part of the operation is well illustrated. This is a vein along the anterior aspect of the temporal tip that was coagulated so I can continue my dissection deeper into the Sylvian fissure. Obviously, the bleeding is magnified and looks worse than it is due to magnification under optical microscope. The patient's blood pressure continues to remain stable. The bleeding appears to originate deeper within the anterior aspect of the Sylvian fissure. You can see I continue my patient microdissection. There's no proximal control available. The source of bleeding is somewhat deeper in this area. I continue the bleeding source and now I have it somewhat well delineated. I reposition the microscope to be able to further identify the exact source of bleeding. Small piece of cotton or cotton-like patty both can be quite effective for gentle and control of the bleeding. Unfortunately, this maneuver obstructs the view to further allow continuation of microsurgery. Again you can see that the aneurysm dome very close to the dura of the anterior temporal lobe is the source of the bleeding. Now the bleeding is quite torrential and I had to use adenosine cardiac arrest to be able to continue further dissection. Second suction is again used to control the bleeding, takes a little bit for the anesthesiologist to prepare the adenosine and make sure its effect is reached. Here, you can see that that the bleeding is identified, however, proximal control is not available. The effect of the adenosine would be apparent in a moment. It's important to have the adenosine ready during any aneurysm surgery so such delay is avoided. I attempt to blindly grab any other structures to control the bleeding. Here you can see the forceps have reached a reasonable point where the bleeding is occurring. There is an arterial branch near the dome of the aneurysm. Use a temporary clip. Temporary clip was initially not effective. This blind placement of a temporary clip is reasonable. Microdissection can now be continued since the operative field is relatively clear. This vessels appears to be in the M1 branch, temporary clip was placed. The identity of a vessel is now more clear since the bleeding is significantly reduced upon placement of the temporary clip on that proximal branch. You now can see the dome of the aneurysm that was avulsed. Another temporary clip is placed across the sac. Bipolar coagulation can also help with control of the bleeding. There's still the bleeding is most likely non-aneurysmal. Irrigation is effective to clear the operative field free. Now that coagulation has controlled the avulsion at the dome of the aneurysm, a longer temporary clip is placed to ensure complete control over the bleeding dome of the aneurysm. Further dissection is continued to elucidate the M2 branches. The dome is again recoagulated. As you can see, it's closely related to the dura or the lesser sphenoid wing. All the important branches appear patent and uninjured during this process. The operator should not indiscriminately injure the vessels during the torrential bleeding. Here's repositioning of the temporary clip across the M1. Obviously I want to reperfuse the distal MCA territory by just clipping the aneurysm rather than continuing the M1 proximal occlusion. You can see the side of the bleeding from the dome of the aneurysm. Permanent clip was used to assure better control over the bleeding site. The blades were placed just at the exact site of the bleeding, second clip was also used. Piece of cotton was also employed to control the bleeding further. The M2 branches appear patent based on micro-Doppler ultrasonography evaluation. The neck of the aneurysm is now more in view. The M2 branches are now followed from distal to proximal direction so that the bifurcation of M1 is in view and the permanent clips can be repositioned to their final configuration. The neck of the aneurysm is now more identifiable. Here you can see the distal edge of the neck and the area of the bifurcation. Temporary clip is reapplied across distal M1. The permanent clip is repositioned to its final position. You can see intraoperative fluorescein angiography reveals good patency of the M2 branches and complete exclusion of the aneurysm. Post-operative angiography reveals good exclusion of the aneurysm without any vascular injury. Thank you.
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