Grand Rounds-Microsurgical Management of Aneurysms and AVM’s: Personal Perspectives

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- Good afternoon, yesterday I addressed pretty much the cavernous malformations, today we're gonna do aneurysms and a couple of ABMS. Is there a laser, could we do if you don't mind going ahead. I think as we tend to work more and more toward minimal approaches, smaller openings, I just wanna show you how we tend to do it these days. Just a little super eyebrow incision for the majority of the anterior circulation aneurysms. Part of the orbital plate so that you really have the perfect angle. And that gives you this sort of approach along the base of the frontal lobe. It gets you right down to the internal carotid artery and optic nerve, really with plenty of room for your routine. The sections, we're in the carotid optic triangle. You can see how distorted the optic nerve is from the aneurysm that is pushing it up. In this case, this is an aneurysm that is really proximal to part of the ring. So we're gonna have to take off the clinoid, and we just take off enough clinoid until we really couldn't see the thalamic artery clearly, but you see the aneurysm over here. I like the Floseal, you can use that just like the Tisseel and put it into the sinuses. I call it the magic stuff because it's such a great hemostatic agent, but just drilling off right adjacent to where the optic nerve is. It's a stiff aneurysm and has some calcification here and as we mobilize it away from the optic nerve, you'll be able to see the ophthalmic artery right here as it comes up. That's ophthalmic artery right here. That's the other side of the neck. And here I'm just hoping that the calcification isn't such that it'll tear the base of the aneurysm. So you can see through this a very small opening, these patients really heal remarkably well. The postoperative incision is very hard to see. Obviously you're gonna have differences among different patients so I always offer them the choice of the bigger incision but just behind the hairline or the smaller one. This is an ACOMM aneurysm where, I don't use adenosine very much, but it certainly does make a difference when you wanna soften up an aneurysm, if you having trouble with clip application. Opening the arachnoid again along the optic nerve, opening the interhemispheric fissure. And then here we see the anterior cerebral artery, A2, see in aneurysm you see an extra little, this is now on the ipsilateral below A2 identifying the perforators there's a little extra communicating which is a dead vessel, which we're going to cut. And you see a little bit of heat transferred to this vessel. You'll see later on that it starts refilling again, fills more and more, and then separating in this space between A2 and the contralateral side and the base of the aneurysm. And this aneurysm because it bulged so far back, we really have to work underneath the A1 the ipsilateral A1 in order to see the perforators coming off the anterior communicating artery, and then placing a clip, A2 is on top, and so we're going to go over that tine over the top of the aneurysm, that's A2 on the other side, and here you see the tine going down between the crotch on the other side. And by being able to visualize it just as we go along, you can really be sure that you're not catching anything else. And then inspecting underneath again, ICG angiography, making sure, and then making sure that you haven't caught any perforators down below. And there's the clip application. You'd see that you really had plenty of room. I don't really recommend it, this is a bifurcation aneurysm on one side, middle cerebral artery aneurysm on the other side. And I don't think it hurts to go across the midline to see. So here's one of the veins at the base of the Sylvian fissure. Here's the ipsilateral bifurcation aneurysm, internal carotid artery, middle cerebral artery, A1 ipsilateral separating it from its adhesions. And then just really going across to see whether we can see the middle cerebral on the opposite side. Here we're going along the skull base, the anterior fossa opening the arachnoid. This'll be middle cerebral artery right below it, the contralateral middle cerebral artery. And depending on the anatomy, that'll allow you whether you can actually clip the other aneurysm safely or not. And as we open it we suddenly see much more, there's a little aneurysm sitting right there, which we hadn't appreciated beforehand but it's not the big aneurysm we saw. So we have to keep going out a little bit further. We're gonna get that little one and then we got the big one that's sitting right there. That's contralateral middle cerebral artery aneurysm. And then once those two are clipped then we're gonna come back and pay attention to the internal carotid artery bifurcation aneurysm. And that's now the internal bifurcation aneurysm, curved clip watching the tines go across, holding down the neck to bring the aneurysm in just the way I want it without cramping the middle cerebral artery that's right underneath or the base of the internal carotid artery. So that's the contralateral middle cerebral artery. And here you see the postoperative clipping contralateral and ipsilateral. This is a patient with bilateral thalmic artery aneurysm. Now bilateral thalmic artery aneurysms are always favorable to be done through one approach. This one is a little bit unique. This is a patient that had a significant visual loss. Ipsilateral, had some bleeding, and as we're exposing you can see the subarachnoid blood. As we're exposing more of the optic nerve you see this hemorrhagic lesion. The aneurysm had obviously bled into the optic nerve and track. So now we have ipsilateral internal carotid artery. This is all aneurysm that we have exposed here. But before we do anything with this aneurysm, now that we're under control we're going to the contralateral side. The vast majority of thalmic artery aneurysm are clipped underneath the optic nerve. This one for some reason stuck above the optic nerve. Maybe that's why on the ipsilateral side it had gone so far into the optic nerve, but very easily clipped. And then we go back to the big one that had ruptured, we put our clip on. And in this case, because I wanted to decompress the optic nerve, put a hole in the aneurysm and see that we didn't get complete closure, opening the clip as long as the blood comes out actually it's not gonna hurt anything. Move the clip a little further. Still the aneurysm you could see is filling, still some filling, probably some thickness in the base of the aneurysm so we put a second clip on that and that's the post-op. You can see the aneurysm completely gone. This is an SCA aneurysm, here we see the basilar artery, we see the SCA aneurysm sticking up. The basilar tip aneurysm are the easiest because they're separation from the perforators. The perforators are easy to see, this is a modified OC, temporal lobe, internal carotid artery, optic nerve. You can go between the third nerve and the internal carotid artery, which is the most common. You can also go between the optic nerve and the internal carotid artery. Or you can go between the anterior cerebral artery and the middle cerebral artery, three different windows that get you access to that region. And it really all depends on the location of the tip of the basilar artery and its relationship to the clive as to which is best. Leaving the arachnoid on the third nerve laterally keeps the third nerve out of the way. We just don't see third nerve palsies with clipping basilar artery aneurysm or SCA aneurysms any more. And that's because we really don't touch them. This is the posterior clinoid, sometimes you have to drill it and get it out. But here are the tines come down, we've opened the crotch of the aneurysm. That's this P1, this is superior cerebellar artery. The only thing I'm concentrating is closing it down and I'm actually lifting up the aneurysm as I do the last closure to get it away from the brainstem. Now I'm looking to make sure that my tines didn't catch anything on the brainstem and you see the tines are completely free but there's a little bit of residual neck. So that makes the clip company very happy that we can add on an extra clip to our construct. Then we do our ICG and we check to make sure in fact that those brainstem perforators are all filling. And you can see it nicely obliterated. This is a patient that had a hemorrhage. You can see a ICA aneurysm. Yes, you could do that through Kawase's approach. I'm incredibly comfortable with the retrosigmoid approach. And we published our series of ICA aneurysms, even the big ones. I think the advantage is you have much more room. This is the sixth cranial nerve that's sitting right here. Easily, you get proximal control of the basilar artery. It is not so easy to get distal control, but it's easier here than I think with the smaller exposures. This is ICA coming out. This is the aneurysm partially embedded in the brainstem. And so what do we need to do is we need to be able to put a tine right here in between the brainstem and the neck of the aneurysm. So you see distal basilar artery continuing on here. And so now we're separating the brain stem from the aneurysm. The PS2 strong, so we have to use a sharp dissection and we'll bring the scissors in a second to separate that layer really right next to the aneurysm dome so that we try to maintain the integrity of the PS, much as possible. Curve of the scissors going in the opposite direction. And we just need to create that window. We need a window for the one tine on this side. And as we get that window further and further open, we wanna go in here, we wanna go in here. Sixth cranial nerve off to the side, Obviously a little bit on edge because you know it's a very fragile aneurysm with its subarachnoids hemorrhage, and here just pulling it away from the brainstem. That's the distal portion, that's the neck right here. And now as you look, we're virtually all the way across. Now we can see the other side of the aneurysm and the basilar artery aneurysm up here. So what we need to do is we need to keep intact this vessel, which is ICA. So the clip has to go far up enough on the neck of the aneurysm to avoid occlusion of ICA. And see the opening, no retractors naturally, just a regular modified retrosigmoid approach. And there's the clip going between the brainstem and the neck of the aneurysm and closure of the clip. And then key naturally is for us to do the ICG to be sure that we've accomplished what we wanna accomplish with the preservation of the branches. So we see basilar artery again, here's the overview, here's the angiogram or the ICG angiogram. And we can see very nicely that the ICAS are patent. Really been a phenomenal addition to us. And you can see the post-opp and it shows nice occlusion. This is contralateral frontal craniotomy for a resection of an AVM. This is one we did just recently. So here the problem is that this AVM is sitting on the dominant hemisphere. The most difficult portion will really be to get all the way to the most lateral edge. And the question is, how do we do that? So what we're doing is for ipsilateral, we opened bilaterally the interhemispheric fissure. We're ipsilateral. This is the large draining vein against the fornix, which is right on the bottom here. And then we put a piece of gel foam between that vein and the AVM and the fornix which is sitting right here. Then we pull the sinus over to the other side. Now we're coming in contralateral, opening the fornix, making a window through which we then are going to resect the arterial venous malformation. So here just opening the fornix, you can see the gel foam poking through. And then once that's done, take out the gel foam and then work to resect the arterial venous malformation. Now we have a very nice view to the most difficult portion of the malformation, no rigid retraction required at all. And we just go back and forth. You'll see the light at the suction to help us see into the recesses. Obviously the feeders from the middle cerebral artery are gonna be the most difficult, but with this approach we really had beautiful exposure of the vessels and control. I put a temporary clip on, but if you watch the vein, it's getting bigger and bigger. That's a good sign to take that clip off if you haven't gotten rid of all the inflow. And then we just keep going, you know, one step after another, obviously leaving that vein intact. Now, if we were occluding the vein and nothing happens, so a clip really just to avoid the small risk of a venous embolism and then taking it on. And this is the contralateral window to this AVM. Really works very, very nicely. Taking full advantage of gravity, retracting this hemisphere and avoiding any additional retraction. And there's the post-op. And this patient is just fine and I warned her that it might be premotor enough to get a problem. This is post embolization. You still see plenty of AVM. Using the fish hooks to retract the scalp. This is something I like a great deal. This is stolen from the cardiac team, and it's basically a refrigeration unit so you can keep your bipolars you're not using in the ice bucket. Because the colder your bipolars are the greater their heat sink. The more heat sink the less likely there will be of any sticking. So I've tried to have companies make them specifically for us just to hold. There's just not enough market to make it worthwhile so borrowing that from your cardiac surgeons really gives you a very nice way to keep those bipolars, the non-stick bipolars nice and cold. And then basically, this constant bipolaring for quick portions along the length of the vessel. Image guidance, you'd think wouldn't make that much difference in AVM. It's very reassuring when you're getting down lower how much farther you have to go, whether you're inside an AVM or you're at the edge of a corner. You can see right here this is obviously a high stake territory for this patient. So anything that makes the resection safer and easier is worth doing, but this constant sweeping portion between the suction and the bipolar. And then again keeping the vein really till the end. And it's very important to skeletonize the veins, because with the veins, there will always be arterial vessels. So if you've got a big draining vein that you leave to the end but you haven't skeletonized it, you're gonna have constant filling of the AVM. So on the left hemisphere, here's the arterial venous malformation coming up. And there's the post-op angiogram, I guess it was the right time. Temporal AVM sitting right here, a little bit of our computer animators work. Michael Hickman, really spectacular capabilities. You can see the post hemorrhage, you see the subarachnoid hemorrhage and the Sylvian fissure. Opening the Sylvian fissure widely, exposing the large vein. And then the typical bipolar cut, bipolar cut, bipolar cut. Odd infinitum, and then having made the decision based on the image guidance and everything we know about the AVM as to what we're gonna take out. we're gonna take out this portion of the temporal lobe. And then we run across all the vessels, especially the periventricular vessels, which are very, very thin. If I'm not sure whether something could be a vessel on I'll put a temporary clip on it rather than take it. And you can see that going across that, whether there's AVM on the other side, we'll determine with a little bit of time. Then creating the other cut. And now we're pretty well around the arterial venous malformation Can see on the angiogram, no shunting. So then we go across the vein and take it out altogether. I still think the AVMs tend to be our most formidable lesions And they can cause you trouble, even after everything has gone perfectly well, when you get that call at three o'clock in the morning, you can have a postoperative hemorrhage, even so the angiogram was negative. So blood pressure control is obviously very critical. And there's the angiogram and that was on the left side. And then this is an interesting little boy. He had a abnormal internal carotid artery dehisced into the ear, had severe bleeding from his ear, and it's not an artery that could be fixed primarily since it was exposed in the canal. So we just excluded it from the circulation. This is just to demonstrate that you can have two teams working at the same time. Somebody getting the radial artery, somebody doing the craniotomy and also exposing the internal carotid artery in the neck. So opening part of the Sylvian fissure, getting a nice branch of the middle cerebral artery. We used to take the radial artery endoscopically. I really don't like that because I think puts way too much trauma on the vessel, much better to have a long incision and handle the vessel very, very carefully. And so depending on the day, depending on the match of the vessels, depending on how worried I am about keeping it open, I will do either interrupted or running sutures. I used to do running all the time. Now, I think I probably do more interrupted than running. Just that the chance that you get less constriction with interrupted sutures and then replace them but we leave them untied so that we can see the enema of each vessel wall as we approximated and then tie them all at the end. And sometimes the tendons are a little flimsy for a thick radial artery. So you really have to follow the path of the needle very carefully so that you don't bend it. These are the little AVM clips which are really nice for the bypass. Then filling the radial artery with a saline and then occluding it, passing a catheter from the head to the neck, putting the artery in it. You may have noticed there's a vascular forceps on the vessel itself where it's bypassed to the middle cerebral artery and then pulled through to the neck incision. We're clipping off the internal carotid artery distally in this little boy, putting approximate clip on the internal carotid artery. That's obviously 12th nerve going across then cutting the internal carotid artery and bringing it out and doing an end-to-end anastomosis to the radial artery, which is a very nice match as you could see. Sometimes these bypasses are much more difficult if there's a little tension on them and your trying to keep the vessels together without pulling through a stitch, putting too much tension on the anastomoses at the cranial side, this one happens to be a very nice match. And this little 11 year old didn't turn a hair. And then always some back bleeding, taking the clips off, allowing whatever stagnant fluid you had inside the vessel to come out and then taking them off for good. And then the ICG, you can see very nicely it filling the middle cerebral artery territory, going from the neck on up. And here's the bypass itself going on up to the middle cerebral artery. Thank you very much.

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