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Grand Rounds-Getting Out of Trouble During Aneurysm Surgery: Technical Pearls

Wink Fisher

February 12, 2013


- Hello, ladies and gentlemen and welcome. We're privileged today to have with us Dr. Wink Fisher from University of Alabama at Birmingham. He is one of the very few in the country with such a big experience in complex aneurysm surgery. He's also a student of Charles Drake, a man that I have such a personal respect for. He will be talking to us about managing difficult moments in intraoperative ruptures during aneurysm surgery. And also includes some of his pearls in terms of how to get out of trouble. Wink, thanks again for being with us. And I'm very interested to listen to your expert comments. Please go ahead.

- Thank you, Aaron. As many of the students of Charlie Drake know, he was probably the quintessential neurosurgeon. And there were many aspects of dealing with intraoperative catastrophes that we all learned from the true master of intracranial aneurysm surgery. I can only pretend to show some of those things now, but after a period of time, there are certain things that we all learn and try to improve upon. And I'm certainly happy to share some of those with you here. When I put this talk together several years ago, this song came on the radio as I was thinking about what to talk about. And I think the song, in some ways, the lyrics kind of describes many of us as neurosurgeons in that we feel we can accomplish almost anything. But as we all know, there are times when these intraoperative ruptures occur and they essentially bring us to our needs. As we deal with intraoperative ruptures, I'd like to discuss a little bit about what the surgical lessons were that I've learned over the years. And then also talk a little bit about the emotional aspect of dealing with an intraoperative catastrophe. Certainly, the intraoperative catastrophes transcend not only aneurysm surgery. Here, we are looking at an internal carotid artery aneurysm, a posterior communicating artery aneurysm, optic nerve, temporal lobe, frontal lobe. And I was watching as the resident used his instrument to what looked to be almost poked a hole within the aneurysm itself. Now, when we think of intracranial or intraoperative aneurysm ruptures, I kind of divide them into two categories. The first being trivial, where the leaking occurs but it really does not impede our progress. There's a little bit of a nuisance, but it can be addressed quite easily. The other type certainly is the serious type that requires evasive action and certainly disrupts the flow of the operation. As we're looking here at this intraoperative rupture, you can see that this is an anterior communicating artery aneurysm, and there's just a little small leak, but that leak is very close to Huebner's and Huebner's artery. And therefore, we have to be very careful not to just indiscriminately go in and buzz that artery to get the bleeding to stop. The incidents of intraoperative ruptures varies from description to description. But it probably occurs somewhere along the lines, somewhere between 20 to 25% of the time. As I've gotten older, it seems like my incidents of intraoperative ruptures are probably less, but that's probably due to the fact that I'd take preventative action prior to actually trying to clip the aneurysm. I think in this original textbook by Samson and Batjer, and there's been another edition since that time, they try to describe intraoperative ruptures and break it down into several different portions of the operation, the predissection phase, that dissection phase, the application of the clip, and then certainly also important with intraoperative aneurysm rupture is the aftercare. More importantly, it should be noted that it's best to try to prevent it at all costs if you can. But when it does occur, we all have to learn how to deal with them. Now, the predissection phase can occur shortly after the patient is admitted to the hospital. And I think that requires certain types of attitudes in the intensive care unit before the patients take an action actually to the operating room. It requires some preoperative planning so that all the members of the surgical team are fully aware of what's going to be involved in the care of this patient's aneurysm. It certainly requires excellent neuro anesthesia. And I think that's an area that neurosurgery has advanced, the care of neurosurgical patients has advanced tremendously over the last several years. And lastly, I think positioning, which is sometimes the hardest part for our residents to learn is also critical in being able to approach certainly the most difficult aneurysms that we deal with in the posterior fossa. The Admission Attitudes of Tom Leipzig and his group from Aaron's institution is a policy that we've established at our institution, which is basically using Amicar. One of my partners has, for a period of time, stopped using Amicar because he was concerned about the amount of postoperative hydrocephalus that we've had. But at the same time, as I discuss on rounds, my feeling is that I'd much rather deal with hydrocephalus than deal with an intraoperative rupture. And certainly, a preoperative rupture that can occur. The other thing that we try to do extensively is enhanced communication with all members of the surgical team. This is a copy of flight plan that's used by airplane pilots, and they have to submit before they take off a flight plan that's filed and made available prior to the time that they actually take off in an airplane. Similarly, we have over the years used diagrams and actually the patient's own three-dimensional CT angiograms, where we label and draw upon just to let people know exactly what's happening. We have kind of a storyboard, if you will, of surgical positioning, pictures that we've shared that's kinda become a standard practice for us so that the residents understand exactly how the patient is to be positioned. But this information which can be shared electronically can also be sent to the operating room staff as well as the anesthesiologist so they understand precisely what's gonna be happening in the case and can make plans for line placement and actually not be surprised when you walk in room. Some people like to post these things on the patient's operating room door. So when they either enter or just entered the operating room, there's a certain amount of human factor that's added to it, that this is a 47-year-old female, that she's a mother of three, et cetera, et cetera, and then have diagrams of the surgical approaches, et cetera. Positioning has always been a very difficult thing for people to understand. And there have been conferences and actually talks in the past on how to position patients for success. I think that's very important in neurosurgery. Probably one of the hardest positions for our trainees to understand, to accomplish is how the patient, place a patient in a park bench position. There some aspects of this positioning that you see here before you that's a little bit different than what we use today. Normally, we don't have the single pin on this side and we also drop the arm down in this region. But the important point to make here is that positioning is very important in neurosurgery, particularly when you're going to be operating through a small space. You wanna have all your equipment available. One of the first things that was apparent to me when I went to London, Ontario under Drake is that he always had three suctions available. And those three suckers certainly are mandatory in the case of an intraoperative rupture, mainly because one could fail. And sometimes, the blood volume is so significant that it takes three suctions just to catch up. We like also having everything set before we open the dura. By that, I mean, we have the retractor system applied, the microscope's been draped in position, and all equipment is present and accounted for before we proceed. The predissection phase is interesting, particularly because of the fact that sometimes, the occurrence of the subarachnoid hemorrhage is entirely unpredictable and it can occur just as the dura is being opened. It can occur while you're moving the microscope. What causes this sometimes, I'm not readily apparent. Fortunately, this is a rare entity. And the main thing that you always wanna have in your mind is to have proximal and distal control if you have to, and certainly, if push comes to shove, brain resection as a last alternative might be necessary. Now, what you're looking at in the upper corner is a older three-dimensional CT angiogram, trying to demonstrate a capital P-I-C-A, PICA aneurysm. And what you're looking at here is an intraoperative video of that operation, and all I'm doing in this particular case, I've started to look around a little bit and I'm going to adjust my microscope. And you can see that shortly after repositioning of the microscope occurs, an intraoperative rupture happen. That was not provoked by any activity of myself. And there were absolutely no swings in the blood pressure. It may have been due to the transmural pressure that occurred at the time of the repositioning, opening of the dura, et cetera. But you can see that we are very quickly applying two suctions in the field, trying not to aspirate any cranial nerves. And then we've already envisioned in our mind where the vertebral artery is so we can get a temporary clip on. We can advance to next slide now. And I think that that slide demonstrates that sometimes, it's really not anything that you do. But as I kind of hinted to while we were discussing about that is that it's important to try to envision the anatomy. Now, we all know our neurovascular anatomy well enough that even though, say for instance, in a very high quality three dimensional CT angiogram, we would expect to see a small A1 on the left side. As you can see in this three-dimensional angiogram, it really doesn't look as though there is one, but when we look at the intraoperative finding, we see that there is indeed a small A1 that was not readily visible on the three-dimensional CT angiogram. And sometimes, if you do not put a temporary clip on this artery and you have an intraoperative rupture, that artery alone can be disruptive enough to make application of the clip quite difficult. So you wanna keep your general anatomy in mind. Look for things that you would expect to see. And at the same time, be prepared to have trapping capabilities present and to have the anatomy well-visualized in your mind before you start the case. Now, the technique of dissection is one that could be a great discussion. I generally like using a number one because it has both advantages and both a smooth surface. And at the same time, a sharp blade-like surface on the other side. The reason is that many times, it's nice to be having, to have a instrument that allows for some sharp dissection. Older particularly as I've become more familiar with Sylvian fissure splits, et cetera, a sharp dissection is something that I do. But the 1 has the advantage of having both a smooth surface, which can be turned towards the aneurysm and a little bit sharper surface on it to allow you to dissect the tissue that's stuck to both the dome and the aneurysm. This becomes important when you are working on the aneurysm, as we can see in this video. So I'm using that sharp instrument to kinda outline the M1, this is a left and middle cerebral artery aneurysm. This is the frontal lobe, temporal lobe, the island of Reil, the inner Sylvian fissure. There is the M1 coming up along the back side. The other M2, you're looking at one of the M2s here, but the other M2 is on the other side. So I just like using that instrument. It makes it very nice and easy. I think the economy of instruments is always best, particularly for the operating room. What you use is up to the surgeon preference. This has been a good instrument for me. Now, dissection of the aneurysm itself. And many times, the word that we used in the operating room is the aneurysm is fused. This is not uncommon in middle cerebral aneurysms. Anterior communicating artery aneurysms are notorious for this problem, making dissection of the artery and the aneurysm difficult. So the thickest part of the aneurysm is commonly down on the body of the fundus, and the apex of the fundus is commonly the weakest or thinnest part. And certainly, that's where the aneurysm is most commonly ruptured. Now, in these elegant cartoons, as outlined by Sugita, you can see that there's always some kind of a plane along the aneurysm. Most often, near the neck of the aneurysm. Now, that makes people very nervous when they're first starting out, because you wanna start out here, which is far away from where your eventual clip is going to have to go. But if you spend the time to develop the plane here, you will actually find that the dissection plane at the neck of the aneurysm is easier to establish than it is over the fundus. Primarily because as the aneurysm's grown over time, it has actually gotten more force and more mass extending against the outer part of the fundus as opposed near the neck. This is of course an area along the neck where you wanna be very careful with your instruments because neck tears can be quite difficult to take care of. So the technique that we use along the aneurysm is to protect, try to protect the vessels coming out of the bifurcation of where the aneurysm occur, try to protect that at all cost. It's much easier to deal with the repercussions of an aneurysm tear than an arterial tear. Consider proximal occlusion, which may cause some of the tension within the aneurysm to decrease, allowing you to establish a better and easier to accomplish plane. Don't be afraid to use sharp scissors. I've seen residents use their bipolars, all sorts of blunt instruments in here, and you're just never gonna get a plane to occur unless you get some kind of sharp instrument in there to at least start the dissection here. And that is, sometimes, all it takes is a little bit of a start, and you're able then with perseverance and time to go ahead and develop that. The sharp dissection should be away from the aneurysm and more towards the artery. These arteries are much more normal in their configuration than the aneurysm. The wall of the aneurysm is obviously abnormal and more subject to injury. We like to do what I call parallel dissection, so that you're literally running your instrument along the aneurysm and along the artery rather than going transversely. And this will allow you then to establish a better plane of dissection. And lastly, don't poke, as we saw in that original video where the resident poked his instrument actually right into the aneurysm, and it obviously provoked a huge hemorrhage. If we look at this video, you can see that the dissection plane is right here along the instrument. And you have to understand that this is around aneurysm, so you wanna kinda go underneath the artery to establish that dissection plane. And if you spend the time, eventually, you'll be able to get to the point where you'll be able to place a clip across the neck of the aneurysm. The width of the dissection that you make here has to be equivalent to a number six instrument, which is probably on the order of three to four millimeters. Most of the times of aneurysm clips are within that width, and therefore, you have to have at least that distance in order for you to be able to get an aneurysm clip in there. In addition, I will look sometimes for what I refer to as the white line. And by that, I mean, it's a color differentiation between the normal artery and the aneurysm. This is particularly useful on middle cerebral aneurysms, where you're not quite sure where the aneurysm begins and where it ends. If you look for that color discoloration, you'll actually be able to kind of formulate in your mind where the native neck of the aneurysm was supposed to be. Clip application can be a little tricky too, in that probably the biggest errors that I've made have been putting the clip on too early. I think if you do have an intraoperative rupture and the clip is providing some type of control, leave it on until such time that you can stop the bleeding. In addition, temporary clipping in our minds is really far superior than to have continuous bleeding. And because of that, we are not, we use temporary clipping all the time. Be strategic in how you approach these cases. You wanna kinda put your temporary clip on the proximal artery first and then put it on the distal ones and not vice versa. So in this video, which starts out a little bit cloudy, you can see that it's the same middle cerebral aneurysm that we showed earlier with the dissection microscopes being moved around to make it more ideal. Again, the M1 is located here. The M2 is here. Here's that white line I was talking about. You can see on this middle circle, there's a little discoloration, a white discoloration there. That's the neck of the, that demarcates where the neck of the aneurysm. Here, you can see that just in the background there was the M2, and then all of a sudden, the aneurysm starts to rupture after a clip is on. That's not a full blown middle cerebral rupture, but it's obviously gonna disrupt our surgical flow and then we're gonna have to address it. This is a case where bipolar coagulation was used to get that bleeding stopped. So we could recollect ourselves and plan on a further dissection and finding out what else needs to be done. You can see the ipsilateral or the frontal M2. It's very easy to visualize. It's what we're having a hard time seeing is the contralateral M2. So you wanna be very strategic about it. A strategy is a big thing sometimes in aneurysm surgery. Now, this is actually a satellite photograph of the beach line in Thailand before the famous tsunami that we're all familiar occurred. And this is of course is after the tsunami has hit and the receding waters go back. The reason I show this slide is to emphasize the fact that blood follows the path of least resistance. And therefore, if you have an intraoperative catastrophe, Sir Lindsey Symon has told us that there is an area around an area that will eventually end up imparted that is borderline in a penumbra kind of idling neurons that can be salvaged if the collateral circulation to that area is improved. And if further bleeding does not rob that area of additional blood flow. Of course, we are operating, when we operate on people with subarachnoid hemorrhage, who are already in an altered state and sometimes, subjecting them to an intraoperative rupture puts this area of penumbra on a real stretch and can be very dangerous. So it's important to acknowledge the fact that there are all sorts of collateral flow within the brain. We have collaterals that are extracranial, as you can see over here. We also have the circle of Willis, which is always our biggest friend. But more interestingly, as shown in these dissections that were performed in the 1950s, there are unpredictable number of pial collaterals that occur not only in the middle cerebral distribution, but also in the posterior fossa. Although these areas are unpredictable as far as number, we know that patients that have larger numbers of these will be able to tolerate long periods of occlusion, much better than those that have a short number or a small number of these. And that really is a challenge for the future is predicting which patients will fall off the Rubicon and get into trouble during temporary occlusion. I think for right now, you just have to realize that probably for up to as long as 50, 5-0 minutes, if you can get bleeding to stop, most patients will be able to recover with few or no neurologic sequelae. I think the important thing to remember too, when you have intraoperative bleeding is that you have to be able to see, you have to be able to use both hands. We are two-handed animals. As soon as you have an intraoperative rupture, and if it continues to bleed and you cannot get control of it, you become a one-handed surgeon. And for those of us who have been in those dire straits, we know that that is not a fun situation. Always realize that there's going to be some downstream ischemia, particularly if you have an anterior communicator that ruptures, and you've got all the temporary occlusion on except for the contralateral A1, that A1 on the contralateral side will continue to bleed and rob the contralateral internal carotid artery distribution of its blood, and eventually also possibly rob the posterior circulation. So stopping bleeding is very important to decrease and go into what we call damage control. One of my resonance had taken, did a study on the patients that we operate on over eight and a half years, starting in 2000 and ending up at that mid-cycle in 2009. And we have been very diligent about trying to mark down our temporary occlusion times. And as you can see here, over those eight and a half years, we had 1300 aneurysms and a thousand patients. And not all those patients obviously underwent temporary occlusion. However, a certain number of those patients, we were able to study. The thing that became of interest to us was that the long standing dogma that 15 minutes of temporary occlusion could be catastrophic for patients I don't think really holds true. And again, kind of goes back to my mantra, which is basically to, I'm sorry, to stop a temporary occlusion or stop the bleeding. If you look at the distribution here over on the left side of this chart, these are the temporary occlusion times that were segmented out. We would first put a temporary occlusion on, take it off, and then put it back in for a second time, third time, fourth time. These are the percentage of all the temporary occlusion patients that we had that had these temporary occlusion done. 47% had it done for one time. 41% had at least two. 8.53, et cetera. And then if you look at the times here that you can look at, you can see that the initial time was 15.3. Secondary time was 6-6-6-6, and 4. So obviously, our first temporary occlusion time, excuse me, was our longest, but we also had some additional times that were relatively long as well. What we found is, when we went and studied these patient, that really the outcome in the patients was not any different than anyone else had experienced, that our results were at least as good as most larger studies have reported. And for us, the important thing was then to try to get the bleeding to stop, use your temporary occlusion sparingly, but don't be afraid to use it. I usually, before I put a temporary clip on, will try to predict that I have approximately 15 minutes left of surgical dissection. That is obviously not always possible to be entirely accurate, but I think it's a good thing to strive for. In addition, my next posture is to try to put proximal occlusion on first, allowing for retrograde flow, particularly if you're in an area, say for instance, in the middle cerebral region where you may have small perforators that, or ventricular strides that could be caught up in a trapping procedure. Many times, the proximal occlusion will allow for us to get enough decompression of the aneurysm to dissect it safely. Moving on then, here is a video of a 14-year-old girl who was sent to me probably close to 20 plus years ago. And it demonstrates many of the problems that you can get into when you're doing a intercranial aneurysm. First of all, the anatomy is not well-established. And I immediately start picking ahead at the aneurysm as opposed to making the efforts to get proximal control. Proximal and distal control, as we all know, are the paramount things of importance. The other thing that you'll notice is as soon as the rupture occurs, you immediately go out of focus. And when that happens, then it's really important to have those three suctions available. And you're gonna see here in a minute another sucker come into the field. And eventually, I'm trying, I will try to place a temporary clip on the aneurysm. And I had tried to visualize before this patient had actually gone to the operating room from her anterior gland where her vessels were. And it was very difficult to tell that, so you're gonna see kind of a blind clip going in here. This is out of focus for a reason in the fact that as we all know, when you're focused in in the depth of the wound and the rupture occurs, you immediately lose your focus. The clip, the blind clip that was placed on there did not work. And so, and you can see I'm barely able to keep up at all with two suctions. Now, a third suction comes into place and then the field starts to at least be somewhat able to be visualized. You are now back in control, and by sucking the aneurysm up into the sucker, the bleeding is going now into the sucker. Again, a temporary clip is placed. It does not work. But suffice it to say, this 14-year old-girl left the hospital in a week after we were able to get control of this and we can move on to the next slide. The important thing to see here is obviously, you can suck that aneurysm up inside your sucker and get control of it. And you read about this in books, and I can tell you, although I don't like doing it because I'm concerned I'm gonna tear a very fragile neck occasionally, that's the only alternative we have. And you're gonna see here this final clip is put on and just to establish enough control that we can eventually start to dissect around the aneurysm and kind of regain ourselves, our composure, and get back in the scheme of things. In no way the final clipping, but it allows us to kind of recollect ourselves and get our composure back and move on. I think it's important to realize that outlining what was done wrong in this video, there was no proximal control. The proximal anatomy was not well understood. That I was picking at the aneurysm well before I should have. And that occasionally, what will happen when that occurs is you wanna try to refocus up high, where you've got the bleeding occurring only to find yourself once you get the bleeding controlled, you have to refocus down. Now, for those people that use a mouthpiece, that's probably not a big issue. I've always never been able to accomplish that skill very well. So we're kind of more of a manual kind of team at least in my operating room. We always have three suckers. I can't emphasize... There's just no way to clip an aneurysm like that without having that bleeding under control. So the prioritization as we've talked about is to stop the bleeding, get proximal control, gain distal control. A blind clip can be used until such time, just to stop the bleeding. There is a thing called an encircling clip, which we will discuss, and then trapping and consideration for a bypass, which is many times a last ditch effort. And unless you're prepared for bypass, it's many times very difficult to initiate. We have found ourselves in some patients particularly difficult middle cerebral aneurysms to actually have a radial artery opened, upper extremity open, the artery dissected free, but not harvested until such time that we're sure we are not going to require the artery for a bypass procedure. I found that this is much more expedient than going in and finding out that you're gonna need an artery, calling the vascular surgeons. We request a vascular surgeons assist us in this matter, have them come in and obtain the artery and then turn around and start attacking aneurysm. Particularly, if you attack the aneurysm and get into trouble, there's no going back. So it's very nice to have everything kind of in your favor prior to moving through those steps. The encircling clip was really brought to the forefront by Thor Sundt, and as you can see, this is a Dacron clip. These clips are certainly available, and there has been many a neurosurgeon who's been saved by these on internal carotid artery tears. And particularly because in those particular cases, the posterior communicating artery can be very forgiving. What this clip does is it goes around three quarters of the artery and has a Dacron graft attached to it that allows for patching and providing a surface for the artery to heal itself. The problem with these clips is twofold. Their availability is sometimes kind of an afterthought for most people when they use them, and sizing the clip, sizing the clip. What you have to do is take this clip and turn it sideways and make sure that that clip is at least as wide when you look down its barrel as the artery for which you were putting it on. And I usually try to oversize. I also try to make the clip as short as possible in that you obviously don't wanna pick up an anterior choroidal artery or something on an internal carotid artery aneurysm. So shortness counts. You have to oversize. It's one of those situations where you'd rather put up with a little bit of leaking, even though you're very distraught to have to use this clip. I'd rather put up with a little bit of bleeding than have an occlusion of a major artery. In this elegant cartoon on your left side by Chris Ogilvy's group, you can see that hemashield has been fashioned and then brought around circumferentially and then clipped with a writing of clip. We've used this technique several times. The downside of this technique is when a rupture does occur, the artery collapses. And again, a little bit of bleeding from this is by far better than having a water tight situation, 'cause eventually, the blood will coagulate and seal itself off. I think our biggest area is usually over tightening this hemashield. Dan Barrow likes to talk about a little wisp of cotton sometimes when he has a small neck tears and then incorporating that inside some type of aperture or right angle clip up against the big artery that many times has helped him in that particular scenario. All these things are very good. Obviously, you wanna keep them in your back pocket when you do these cases. All right, and lastly, I'd like to move on to the emotional aspect of having an intraoperative rupture. Several years ago, this book came out, "Good to Great." Many, I'm sure, of the people who are watching this video have read this book. It's an interesting book by this fellow, Jim Collins, on dealing on how to make companies great instead of just good. And that's what we all wanna be as neurosurgeons. We wanna be great, not just mediocre. And in that book, Collins talks about Stockdale Paradox. It's interesting. This fellow Stockdale was a Navy pilot and eventually became an admiral, but he has the congressional medal of honor that's displayed on his chest medal there. And it turns out that he was in Vietnam, flying Air Force in 1965, and he was shot down over Vietnam and captured. During that time, he was imprisoned in what was affectionately called Hotel Hanoi. Here's the actual cell that he was in. And here he is in 1973, just before he was released from that prison. What's amazing about Admiral Stockdale is some of the deprivation that he endured during that time. He was in captivity for seven years. One of the longest times that any prisoner of war had been in a confinement. He was tortured 15 times. Had to wear vise-like leg irons for two years. And more importantly to me was the fact that here's a guy that spent four of the seven years of his confinement in total darkness. So when you feel you're having a bad day in the operating room, just remember that story. The Stockdale Paradox basically talks about two things: retain faith that you will prevail in the end regardless of the difficulties. And I think that's something very important in neurosurgery, even in worst case scenario that you have to believe that you're gonna pull this out and never let yourself give up on yourself or the patient. But the other thing is you have to kind of also be able to confront the most brutal facts of your current reality. And I think, so when I was called in to assist this case, that the resident had gotten into, the first thing I thought is, oh my God, how am I ever gonna be able to see? And eventually, we got this patient better and she went home. So the Fisher version of that is expect the worst, pray for the best, and be prepared and then dive in. And that concludes my talk.

- Wink, thanks so much. It really is spectacular talk. I personally learned some from it as well. One of the factors that you described is that it seems like as you gain experience, most often, your intraoperative ruptures occur during clip application rather than pre-clip application, which most of the pre-clip application ruptures have this in people with less experience. Would you say that's the truth?

- Yes, and I think the reason that occurs is probably because of several things. You have not learned yet early on how to establish brain relaxation in many ways, either from a CSF standpoint, from your dissection, from your retractors, and the fact that you do a lot more pulling rather than sharp dissection. Your dissection planes are not as good. So in essence, I think that's probably why those kind of ruptures occur early in your experience. The other way that they might occur is the fact that I'm much more, it's much easier for me to go ahead and perform temporary occlusion in patients. I feel very comfortable about using temporary occlusion. My staff is very comfortable with supplying or giving me the clips that I need. You wanna be strategic about how those clips are angled, positioned. You don't wanna have what I call battle of the hubs, where you have 5,000 hubs sticking right where you wanna try to place your aneurysm clip. So you wanna try to get the temporary clips out of the way. But like I said, if I think I have about 15 minutes left in the dissection, how many times put proximal clips on. Typically, for example, if I'm doing an anterior communicating artery aneurysm, I will put a temporary occlusion clip on the contralateral A1. That's usually one of the harder ones to get a temporary clip on. Many times, the left A1 is dominant or large, and that will many times make people wanna consider going from the left side. Generally, for an anterior communicator, no matter what, I'll go from the right, 'cause I'm right-handed. It's what you're comfortable with, basically. So I think the bottom line is why these things occur early on is probably due to the fact that you're just not used to, the residents, they know what you can get away with. Can you get away with a little bit more of a tow in here? Can you use a little bit more sharp dissection there? When do you put the temporary clip on?

- I really liked your strategy about liberal use of temporary clips. I personally have found that absolutely critical, because to get that aneurysm deflated, look around it really well. Sometimes, when you get to an aneurysm that's also sitting in your face, your blood pressure goes up. You really wanna put that clip and get out of there. It's just unfortunate especially when you're tired. You've had a long day, a tough dissection, but if you take your time, put that temporary clip, deflate the aneurysm. We dissect around the neck. And that extra time of deflation, the looking around the neck all the way across the neck, understanding the anatomy very well, and then applying that clip, I would say that is the number one reason for me to decrease my intraoperative rupture. Would you believe in that?

- Yes, absolutely. And as you may or may not remember on one of my slides is I put, I found that one of my errors early on was I put clips on way too early. The commonest place for that to happen is in the anterior communicating area because you can't see. I mean, it's midline. Many times, the aneurysms are projecting behind or they're underneath the anterior communicating complex. It gets difficult to see in that particular case once you've got a clip in, whether you've actually done a good job. Many times, we would see Drake actually take a bipolar, and just close the bipolar across the neck so he can look around. You did not coagulate, you just, if it was de-pressurized, he'd see kind of what that little bit of pressure did to allow him to look around. And I agree entirely. I think that the more you have the anatomy established, and in particular, after you're convinced that you got a good clip, you need to still spend a little time verifying in your mind that that aneurysm or that you have nothing in the jaws of your clip that you're gonna be reluctant to deal with later. You will never have a better opportunity than at the time of surgery.

- I agree. If you are, you know, again, the problem is that when people do very few aneurysms in a year and because of endovascular surgery, the comfort level to dissect the aneurysm is exponentially decreasing. We all know how to expose aneurysms. That's not the difficult part of the surgery. It's that extra 15, 20 minutes of the surgeon understanding what should get away with after you put a temporary clip on how you can look around the aneurysm, make sure you have cleared the path or the clip blade completely. If you're doing an ACom just like you mentioned, it's the most difficult one because you have so many vessels. There is little space to work with. Also, for vascular aneurysms, because you may have a perforator on the other side that you're not seeing very well, it's not for the clip blade to do the dissection. The clip blade has to go extremely smoothly. And when you put a clip, that should be easiest part of the operation, because you have already done all the work. It's just going in, and there's no discomfort because you already have dissected around it completely. If you're putting a clip and you have even a little bit of doubt, I think that means you should listen to yourself, don't you agree?

- Yeah, yeah, absolutely. I think physically, one of the most difficult aneurysms is say, for example, a giant ophthalmic where you have to take the off you have to do dissection around it, but that's the quintessential example of complete dissection. And the clip is the icing on the cake. The clipping, the actual putting the clip on the aneurysm is the icing on the cake. It's easiest part of the operation. But the hardest part is getting there, exposing it, making sure the ophthalmic is free, et cetera. Anterior communicators, again, as we said, they are the hardest to see around once you've got a clip in and if you're not perfectly happy with it once it's on there, very difficult to see around it, particularly in a patient that's had a subarachnoid hemorrhage.

- Very well said. I can emphasize the great points you just mentioned. I'm gonna go ahead and include a couple of cases with your permission, Wink, can get your expert opinion. What would you do in these circumstances? The first case is actually from quite a while ago. A 42-year-old female with presented with severe headache and passed out was initially localizing. And just as I got to the ER to examine the patient with our residents, started blowing her right to pupil. As you can see, there is a large right frontal hemorrhage associated with most likely anterior communicating artery aneurysm. They did a CT angiogram pretty expeditiously as though we're doing this CT. And you can see there is a nipple on the aneurysm and probably a broad based aneurysm. The right A1 is dominant. Looking at this case, obviously surgery, trying to decompress the clot a little bit, not too aggressively, and then approaching the aneurysm subfrontally. Would you consider any other important pearls here?

- Some people, particularly if they're inexperienced, would say to themselves, well, let's try to coil that aneurysm and then take them down for an emergency evacuation in the hematoma. Really, in my mind, that's exercise in futility and that this patient's best chance is for you to go in and decompress the blood clot and then deal with the aneurysm. One of the things that I've been surprised about, particularly in the era of Exelon anesthesia is our ability to decompress these patients' clots and not have the aneurysm re-rupture, even when the aneurysm rupture occurs acutely. For example, a patient that may work in your hospital and is working in your hospital and suddenly drops to the ground, goes down, gets evaluated, comes up with a scan like this. So generally, the following principles would be adhered to in this particular case. I would, number one, prepare this patient for a approach to an anterior communicating artery aneurysm. I would expeditiously open a nice, generous craniotomy, possibly a little bit larger than normal, just so that we would have free advantage to removing the clot. The situation here is made quite easy in the fact that even though you said the right A1 is dominant, I can't tell that from these images here, but the clot's primarily on the right side. So it makes decision-making very easy from that standpoint. Generally, we try to look if we have a three-dimensional CT angiogram, see if there's other aneurysms. It's terrible to get done with a case like this. Have the patient do well and then suddenly find out they got a little tiny, easy posterior communicator or a tiny middle cerebral aneurysm that could have easily been addressed at the same time in those surgery. Particularly in middle cerebrals because they don't do very well with endovascular therapy. So then the next thing I would do is because the brain will be very swollen here, it's good decompression. That would include positioning, anesthesia. I would immediately go into funnel clot. I might not take the entire frontal clot out. I might leave some behind, as we have all who have done aneurysms of this type. You can get down in the end of the clot, and you're gonna find the aneurysm, and it's gonna bleed on. So generally, what we try to do is leave some of that clot in there, go back around, reestablish our normal dissection plane, get proximal and distal control, clip the aneurysm, verify good flow, and then go back out through the hematoma cavity to remove the rest of the blood clot that's there. I have found that if I leave a large percentage of these blood clots in patients over a period of time, they can become problematic. And generally, I like to remove within reason, without causing a lot of brain injury as much of the blood clot as I possibly can. I think that the secondary effects of the clot on all structures of the brain really is not helpful for recovery. And therefore, we try to remove as much of the blood clot. Then I think postoperatively in the intensive care unit, you wanna have CSF diversion if you can. Now, in this particular case, placing a ventriculostomy might be somewhat challenging. So we leave cisternal drains in. I've had patients with both ventriculostomies and cisternal drain. When we have both, I just wait and see how the patient does and then start to pick out whichever one I think is functioning less later on. I have absolutely no hesitation of putting a cisternal drain in and draining spinal fluid that way. You don't wanna be hurt by hydrocephalus in a patient who has this kind of caliber of clot. But as I tell the resident, a patient who has this kind of clot many times will do very well because their subarachnoid blood is at a minimum. And that the blood itself is actually entrapped within the brain tissue, which sometimes, it's remarkable how well these patients will do.

- Well, I think I couldn't have put it in better terms. Let's go ahead and see the video in this case. I did go ahead and decompressed the clot in the right frontal lobe somewhere, not too much, and then cuts up funnel. And then the aneurysm dome was very attached as you can see here to the optic chiasm. We still not able to see A1 ipsilaterally. I try to carefully, again, this is the right frontal lobe, temporal lobe. The dome is very attached to the optic nerve and chiasm. I cannot see A1 because there's a lot of clots still there and try to somehow as scruffy possible create a plane like this attachment was just actually too intense. That's one of the reasons why it blew upward. And here is you can see a lot of bleeding happening because I tried to mobilize this artery and I got into the aneurysm itself. At this juncture, before I tell you what I did, you had a tracheal bleeding, you don't have proximal control. You have a swollen brain, and you're at the location of anterior communicating artery, which is very difficult to see around. What would be your thoughts?

- Well, to me, these anterior projecting aneurysms are the most prone to intraoperative rupture as opposed to the posterior projecting ones. And as I tell the residents, they're the easiest to clip, but they're the most difficult to get proximal control on. And the reason is it's because the dome itself lies right in the avenue of where the contralateral A1 is, and you don't have the ability to get there sometimes very easily. It seems sometimes in these patients that that opposite A1 is very posteriorly located. And particularly, with clot and et cetera, it can be quite difficult. My sequence of events with this kind of bleeding is to aid, verify that I have all three suckers, that they're all functioning well. Initially, when you have that little oozing, I might've been inclined to just put a soft little Cottonoid on it and try to get that stopped. But you're at the point now of no return. My next step would be probably to place what I call blind clip after I've placed temporary occlusion on the ipsilateral side. I can't quite tell from this video whether the A1 on the ipsilateral side is exposed or not, but I would try to get as much temporary occlusion as I could, and then probably place a blind clip across it. If that doesn't work, then you're gonna have to go and actually mobilize the dome. And that can sometimes be fraught with complication as you are well aware.

- I think that's what we had to do because we did not have A1 exposed on this side. The brain was still too tight. Maybe more blood clots should have been removed. So Yasargil and Charlie Drake have described this technique of proceeding with coagulating the dome. As you can see, I'm trying to stay from the optic nerve. We have extra suction and I can actually get nothing under control very well. So you don't wanna coagulate very indiscriminately to injure the optic nerve. So coagulate the dome as much of it you can see, leave a piece of coagulated dome on the optic nerve, and then cut the dome across the aneurysm to be able to get some control and over the ipsilateral A1. So we coagulated dome, left a piece of the dome coagulated on the optic nerve to avoid any injury. And that allowed us to identify the ipsilateral A1 which we can see here. You can see that piece of dome was left on the optic nerve. This is the dome itself above my suction. And it finished treated clip straight was placed, obviously preserving the perforated scoring posterior, and again, this is the aneurysm itself. So obviously, this is a salvage situation. You wanna avoid coagulating blood vessels and aneurysms at all costs, but sometimes, you're left with no choice. And this may be one of these situations.

- I think in that particular case too, Aaron, the fact that you did such a good job with that emphasizes the fact that you had in your mind a preconceived notion of how that aneurysm was lying within the operative field. Coagulation, you know, just what I call wild and crazy coagulation scares me because particularly, when you're in a tight hole, but you had in your mind, obviously, envisioned how this aneurysm was going to be configured. And because of that, you were able to do-

- You're very right.

- And it's a viable technique that it has saved me many times. You have to be careful with overzealous coagulation, too. And the fact that we've kind of do a graded amount of heat on the bipolar, obviously, in a situation like this, you don't have much choice. But particularly, if you're doing small blebs, et cetera, we're very, very, very careful about overheating the parent arteries. I'd advise people to use it with caution, but it's another part of your armamentarium, and keep in your mind envisioned how that aneurysm is configured. It'll help you every time.

- And you know, this is the post-op CT scan about a month later. And you know, just like you mentioned, you really have to remove these clots really clean after you clip the aneurysm. And one of my mottoes has always been, it's better to be lucky than good. And this is the classic example of this patient doing very well, obviously showing the picture with her permission. And you definitely, if you're operating on somebody who's working at the White House, you better get a good result because this is a letter actually, President Bush sent to her after her recovery. Let's go ahead and talk about another case and close this session. A 62-year-old female with the nuance of subarachnoid hemorrhage and previous history of left P-Comm aneurysm clip. When you have had a previous history of subarachnoid hemorrhage, all the systems are very scarred and that can create a significant challenge. The other issue that I have run into trouble with is carotid artery at the skull base is the highest blood flow system in each cranial circulation. So if you get a hemorrhage, it's the most difficult one to control. If you have a broad-based aneurysm, clipping get perpendicular to the parent artery, which is the ICA. Can be challenging because the clip may not close. So broad-based aneurysm is critical to use the angle clip and try to go parallel to the carotid artery. In other words, put the clip, one of the parallel clips just medial to the aneurysm neck. What it does is that if you put a clip and you don't close all the way, it's like a hose. If you put your finger in the hose underwater at the tip of the hose, you increase the flow within the aneurysm sack and you get an intraoperative rupture. And so this case that you will see the CT scan right now, this patient previously had a surgery on the left side, previous craniotomy, a broad-based right side, a lateral pointing aneurysm. This was early in my career. I did make a mistake of putting the clip perpendicular. I ran into very large intraoperative rupture, and you will see the video. I did not appreciate the anatomy very well and placed a very long clip and sacrificed two perforators. And as you can see, unfortunately, the patient suffered from an internal capsule stroke, and she has remained to this state, hemochromatic, and obviously a very badly solved and undesirable. So I'm gonna show that video and I would appreciate your thoughts here on how you would have managed this different. Here is, by the way, before we proceed with the video, a right-sided craniotomy temporal lobe, frontal lobe. This is the optic nerve. This is carotid artery, very scarred in from the previous subarachnoid hemorrhage. A very broad neck. I think here, trying to put a clip perpendicular, you're not gonna be able to close your clip. You're gonna do accordion effect on the carotid artery. You're not gonna close your clip. You're gonna have an intraoperative rupture. I should have used an angle clips on here. Make sure that anterior carotid artery was kept intact. What other pearls would you have with us, Wink, here?

- Well, I agree with you. This is a extremely scarred in large bolus aneurysm. And Drake used to emphasize emphatically that what I call a cold planer clipping is better than a tangential one. Now, when I see an aneurysm like this, I usually try to look in the opticocarotid triangle. This I assume is the optic nerve. This clip here is on the internal carotid artery. This is the opticocarotid triangle. And I try to look in here and find the posterior communicating artery. Posterior communicating artery, it's either going to be traveling posterior or it's going to be going lateral around this aneurysm. Those are the two primary configurations that you'll see. In addition, when I see an aneurysm this wide, I immediately go into thinking about a multiple clip scenario, requiring probably an aperture, a clip that's gonna have to require a stacking of clips over this distance, just because I'd really feel that trying to draw this whole thing together is difficult. Wide look for the posterior communicating artery, because I wanna be able to get a temporary clip on that. I want this A1 out and free to get a proximal or temporary occlusion on. I wanna see this M1. I wanna be able to temporarily occlude it, because if this thing goes, it's like I tell the residents, you'll never see so much blood in your entire life when the carotid already breaks open. And these wide base, particularly this one's lateral, but many times, they're underneath the carotid artery and projecting over towards the optic chiasm, towards the pituitary stalk can be extremely difficult. Now, Fukushima talks about dissecting off 90% of this dome. And the reason that is is because the tensile forces of the brain that's adhered to this aneurysm will make closure of that aneurysm, not only from a standpoint of what you have to deal with with the neck. It's also adherent over here with forces that aneurysm open. Sugita I think used to say you needed at least 50%, but Taka feels that you need to have 90% of this thing exposed, which I really kind of think is probably not too untrue, at least enough so you can manipulate this dome around. An aperture clip in this particular case is going to be somewhat difficult. Your angle of approach for that aperture clip is gonna have to be like so as I'm moving my arrow. And by freeing up this dome, you might be able to actually push the dome down so it'll accommodate an aperture clip easier. Lastly, you need to know where that posterior communicator is because it can present a large source for bleeding and make this aneurysm very difficult if you can't get a temporary clip on it. So we always look in there.

- I couldn't find the P-Comm. It was so scarred in. Maybe I should have not quit that early. So I have proximal control on the ICA here. You would see probably the torrential bleeding's not bad, but as you will see, I did not have the P-Comm. And this is what happened. I made a mistake of placing the clip on to the aneurysm in a perpendicular fashion. And here we go. You will see the intraoperative hemorrhage because I didn't have the anatomy very well-oriented. Here, I'm a left-handed surgeon. I came in with probably a short clip, perpendicular to the aneurysm. A horrible mistake. And the clip will not close completely and will cause really a very significant hemorrhage. You don't wanna play too much with the blades to do the dissection for you. You can see here that I'm just not very comfortable placing the clip. The blades are not going easily. And that's, again, because of the tremendous amount of scarring. What would you do at this situation, Wink?

- Well, one of the things you need to do is kinda try to find out where the hemorrhage is coming from. Is it because you used too short of a clip or is it because of the fact that your clip attack is wrong? Getting the tines to do your dissection is very good point. I tell the residents that that clip tine needs to go in there like cutting butter. It needs to just slide right in there. And it looks like you've applied a longer clip now and you've gotten some control. So the thing you need to do now is dissect everything out and try to find out what you've got going on. It looks like you piggybacked a clip on top of it, and that's a little bit longer. So you used that, one point I talk about is use the clipping that you have. It's probably that plus your proximal occlusion has probably stopped the bleeding to a certain amount. And then lastly, the co-planer or parallel clipping technique is by far superior. Sometimes, you just don't have a choice and you have to go tangential. But if you could figure out a way to go co-planer with that aneurysm-

- I assume because of the scar, I ended up not being able to dissect more nerve clips as they are. I start at that point. Maybe it's best not to make it worse. Probably, my clip went this way because I didn't have a great appreciation of the anatomy of the region. It's very easy when you're looking in a blind way from front to back is that you put the clip this way rather than really flush with a carotid artery. And I think that was another error was made in that case. And really ultimately, it comes down to dissect the anatomy, take your time, use temporary occlusion, and has to blaze like a piece of knife on the butter. Do not do dissection with a clip lights. I wanna thank you, Wink, for really a spectacular discussion. And personally, I found it very instructive.

- Thank you, Aaron. It's my pleasure.

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