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Grand Rounds-My Pearls of Technique: A Review of Challenging Cases

Robert Spetzler

June 15, 2013


- I thank all of you guys for joining us this afternoon. Again, my name is Aaron Colvin, from Goodman Campbell Brain and Spine. We had a great talk by Dr. Michael Lockton this morning regarding the passion for cerebrovascular surgery. And often we talk to ourselves or talk to our friends about what is that finesse, new ounce, technique, touch, that make a surgeon with AR the expect surgeon. I don't think we can ever define what that is, but maybe by watching some high quality videos, we can at least witness some of those moves. Therefore, I would like to introduce our panel of experts. I think Dr. Spetzler requires no introduction. He's truly the master surgeon who has defined so many of the microsurgical techniques we use today. We're gonna start with his surgical videos this afternoon, and we're gonna move to Dr. Michael Lawton, and other master surgeon. Who again, give a spectacular talk, discussing some of his techniques. Following that, we'll go to Dr. Troy Painter, one of my senior colleagues and a spectacular surgeon who will review a cavernous malformation in the brain stem. And if there's time, I will discuss on my surgical videos. Dr. Spetzler, thank you for being here.

- So the first case, is really one of the contralateral meningioma. By contralateral I mean that the approach is from the opposite side, the patient's head is horizontal like it is here, so that gravity is pulling down on the hemisphere that's dependent. We have cut the POCs, and now we are looking right at the meningioma and bringing it into view. The advantages of that particular approach, naturally are that first you'd require no retraction. Second of all, the most distal portion of that meningioma is much easier to reach from this angle without retraction. Then if you were on the ipsilateral side, cutting a little bit more of the falx, obviously making sure that we protect the vasculature. And then I really use the suction as a retractor, as well as its suction capability. And the key with that particular instrument is that it has a teardrop opening. And when your finger is off that little teardrop, there's absolutely no suction going through the other end. So you could be right on the most eloquent cortex and not heard it. And you can see through a very small opening. I don't think that's gonna show how you can take out this particular meningioma. And here's the post-op patient went home, I think a one or two days later. This is for a cervical ependymoma. You can see here, that the position, the incision coming down to the arachnoid. You can see the bulge of the tumor very nicely. What I wanna demonstrate here particularly is that the central vein, it's often right over the exact midline. So you would normally just interrupt it. But now, instead of interrupting it, I take the branches, cut them, and then mobilize the vein off the midline, trying to keep it intact. So that at least the venous drainage from whatever side still has the attachments, like on this side are intact and keeping that large vein intact. Like we have to be very respectful of veins and the more we can be respectful and the better it is. So this really emphasizes that point easily moved off the midline. And then once we have the midline identified, this is a little diamond knife. We've actually developed some forceps, which are sharp forceps, but a little broad like a knife for spreading, just to open the spinal cord like this here, except that the tips are very sharp. And then I've given up PO sutures many years ago. And the reason for having given up the PO sutures is that they've fixed the PO to the edge, rather than allowing the spinal cord to move with you as you go from one side to the other. And by going from one side to the other, you have much less traction on the spinal cord and then just removing the tumor in the usual fashion, you see this constant movement that is because of the use of the mouth switch, so that you're always putting it the microscope in a position where you have the best vision and the best light. For these tumors, obviously the vascular blood supply is mainly from the anterior cerebral artery. And here you see the post-op MRI scan. This is a Retrosigmoid Approach for resection of this particular tumor, remember that cystic acoustic tumors have a significantly worse prognosis than those that are not cystic. And so we have to be even more aggressive with those that are cystic. Important, I think is to make the incision along from its entrance to its exit. From the brainstem to the course of acoustic cyst, because, you can't possibly interrupt anything important. And then separating that thin little arachnoid membrane, everything that's functions is outside of that arachnoid membrane, sometimes very difficult to establish, but the more you work on maintaining that membrane letting it bleed some rather than using the bipolars, separating the eighth nerve bundle, keeping the vascular supply intact, and then using the ultrasonic aspirator to gain more freedom and more loop. You can see the eighth and seventh nerve bundle. Seventh nerves underneath here, very well-protected and then taking it out completely little remnants of tumor. And here you see the bundle with just a little bit of tumor left the end of the course. This is where you want to be particularly careful because when you stick in those instruments, you can easily injure the eight nerve. And the whole thing naturally, without a retractor. No change in hearing. This is a Temporal Arterial Venous Malformation, showing up some of our 3D graphics. This is a patient, you can see the sub rack, my blood. And then basically the key being, identifying the draining veins and the feeding arteries, and then having relentless patients and going along the edge of the arterial venous malformation, opening the fissures, staying between the PO layers. And I think key is opening the fissure far enough so that you can actually get around the ABM. As it turns out underneath here is all ABM in the soft, the tissue. You could see that on the MRI guidance. I have, I use two bipolars routinely. One of them is an ice water while I'm using the other one, remember that the non-stick properties of bipolars have to do with a number of things. One of them is the heat capacity. So that's why these are a little wider. These are the ones that I love carrier, my name, but the secret is that they're smooth because they're throw away. And the other secret is, is that they're always cold and therefore a work better. A lot of this here is impacted because of the preoperative embolization that was used in this case. This is the fuse ABM in the sense that it has much more, much less sharp order than many leaving the veins for the very end. Using ICG to make sure that you don't see any more Shawns. And then finally taking the last component of the arterial venous malformation to take it out. This is a patient with the cavernous malformation here. When you look at the extent of the section, so just a little opening. This is a patient that had bled a number of times, going right to the cavernous malformation. You see the cystic component from the previous hemorrhages. He was a physician, very concerned about his neurologic function, but you can see really by going just through a fissure, going right down to the Cav-Mal. Identifying the portion of the venous anatomy that is part of the Cav-Mal that you have to sacrifice, and then making certain that you preserved the large associated veins that drain normal brain and here coming right out. I think one of the other things that's worth observing is that you're obviously under high power. Why would we have the microscope unless we really use its full visual capacity? And that happens when we're on high power, so that we can see the small vessels and small nuances. At the end of removing a Cav-Mal, I spent much more time now going around the edge, looking for if there's anything still additionally, that's suspicious, particularly little white fibers in the bed, and I'll spend a lot of time picking all those out with little forceps that have little teeth on the end until I'm as confident as possible, and here's the post-op. This is also a cavernous malformation. Not that similar off the midline, but in this case it's here. So what we're gonna do is, we're gonna go contralateral. We're going to, here's the falx, the dependent hemisphere again, is hanging down. We're allowing anatomy and gravity to help us. Our eyes are horizontal, our hands are horizontal. So why would we wanna work in a slip that's vertical? That's one of the reasons for the horizontal position. And in this case, we went right through the cingulate gyrus to get us right to the cavernous malformation, the typical hemosiderin stain-like surrounding edge of the cavernous malformation. And then again, making sure that we take everything that is in any way, reminiscent of cavernous malformation. And here you see the empty bed. Here's one, that's a little deeper. So we're down getting more to the third ventricle, in which case the position is all there as you could see here. We're opening into the lateral ventricle, you see the septum and you see the Pelham astride veins. You see the choroid plexus, we've identified our entry point with image guidance, and then make a small opening directly into the cavernous malformation in this case. And then debunk some of the cavernous malformation, take out some of the more recent hemorrhage until our opening is large enough to put our instruments in. Many times when you're working in very small holes, your visualization is inadequate because of light. So utilizing light at instruments like the sucker, which has light attached to it, you can aluminate the area of interest. And by constantly moving your microscope, you get the best angle for the particular area of interest. So if you're working at the edge, which is really not the best, except that our combined light gives us the best angle to the edge. And you can see spend a lot of time identifying the little white fibers, all of which really need to be removed in order to minimize the risk of recurrence. All of that is still Cav-Mal. Sometimes just using the sucker and the forceps with the sucker, being a conference attraction, and removing that piecemeal. And there you see the opening. You obviously see the apponex was completely intact and there's the empty whole. This is Left Retrosigmoid Approach for this cavernous malformation. Patient is supine with the head turn. And here you're going down into the retrosigmoid space opening the arachnoid fissures. Nine, 10, and 11 to your left, seven and eight to the right five down deep. Having identified where we wanna enter the brainstem. We first start emptying it out. You see six down below. I love these little forceps with teeth on them, to grab onto the tissue, and then using traction from the sucker to mobilize the iragnoid brain which has a few vessels in it, and then removing the carvernous malformation piecemeal. And then again, spending a long time, inspecting the bed to be certain that we have removed it as completely as possible. Six down below cavity. And there's the postop with the cavernous malformation done. This is the midline craniotomy for a cavernous malformation that you see here. That's obviously back in the third ventricle, a little more difficult, deeper, you'll see the third ventricle where it's sitting. Opening interhemispheric approach, opening the colostrum, heading straight down to the cavernous malformation, opening the third ventricle. And by opening that third ventricle, we're going right down toward the aqueduct. We're utilizing the light, we're protecting the fornix or third ventricle, absolutely beautiful view. And there's our carvenous malformation way down deep. But once we can visualize it like this is going right into the aqueduct. Opening some of it using these very small instruments, pituitary like in nature and after the going around it as much as possible, pulling it out, if there's any tension, a lot of tactile feedback using the sucker to hold back the normal tissue to allow us to bring it out. And then you're staring right at the floor of the third ventricle. And there's the empty cavity where the cavernous malformation was. It's a young woman from Israel who did very well. Far Lateral SupraCerebellar Approach is absolutely ideal for lesions that are in the midbrain accessible through the ambient fissure. It is such an elegant way to get down deep to the structures of the midbrain and a high ponds, a small opening. This is the sinus, obviously cerebellum separating the cerebellum from the tentorium, and then following the tentorium down, opening the ambient cistern, and assessed such incredibly beautiful anatomy. And then we're going right to the cavernous malformation superior cerebellar artery is down there opening the midbrain. And it's not infrequent that you're confronted with significant carvenous bleeding because these are really being us anomalies. You just have to remember that they are veins. They are easily controlled with a little bit of counter pressure and that they should not keep you from removing the cavernous malformation naturally equally important is to preserve those large veins, which are in the vicinity that drain normal brain that must be preserved. And always a little bit of counter pressure pushing the vessels out of the way, so we don't tear them. And obviously if the piece is too big, then we cut it either with a CO2 laser or micro scissors automation. You see the aneurysm, you open the Sylvian fissure, and as Dr. Lawton. So we'll emphasize this morning and the Hon Wilson lecture, the ability to open the fissure remains key. I think the ability to do that without using fixed retractors not that there's anything wrong with using them. It's just that you have much less tension on any side. Here, we have an aneurysm that is extremely adherent to the other vessel. So we're gonna coagulate it in order to be able to separate it from the wall of the vessel that's down deep. Cut across it so we can preserve it this here. It's cutting the aneurysm itself, really to get to this spot, which is the edge of the neck. Here's another one of those big branches. And then incorporating the neck of the aneurysm after it's been bi-polared. into this small clip. And here you can see nice preservation on the vessel on the other side. ICG naturally always ensures that we have patency and here's the postoperative elimination of that aneurysm. These are difficult aneurysm. This is a patient that was losing vision in that eye, had bad headaches. Here we're opening the arachnoid fissure. You can see some blood, optic nerve. Right internal carotid artery below there, the aneurysm. And then going to the other side, we're now on the other side and looking at this ophthalmic artery aneurysm. Now we go back to the one that had hemorrhage, put a clip across it. I wanted to decompress the nerve, therefore open the aneurysm. We could see that the clip was not adequate. And so any time the blood comes out towards you, you're not gonna hurt the patient. It's when you panic and you put a Tampa nodding effect on the bleeding side and force the blood down deep into the subarachnoid space that the brain comes out at you, patient tolerate that rate of this very long. You can see, this is for an aneurysm that's you see here. This is also from a physician's family, very difficult, the aneurysm, as it turns out, expose it. So I use a temporary clip on the opposite side in case it ruptures. And you can see it's attachment working under high magnification, separating it from the anterior cerebral artery A1 and A2 going around it. And then applying a clip, sort of grabbing it, utilizing your sucker and bringing it all together, like a net so that we incorporate as much of the aneurysm as possible. And then removing the temporary clip on the opposite the A1. ICG nicely demonstrates that you have low in both A2s scene right here. And here you can see the nice occlusion. For an anterior cerebellar artery aneurysm you see this one here, very difficult. One with the subarachnoid hormage, you see PICA below. We're gonna go in from a retrosigmoid approach. If you're really the problem is to get proximal and distal control of the basil artery in front of them behind the aneurysm. So you see the six cranial nerve, draped over the dome of the aneurysm. You see branches of ICA. This is Basler artery that's exposed right there, seven and eight Praximal, and then separating the aneurysm from its origin. And from the basil artery, you see a branch of ICA coming here. You see main of ICA right up here. So we carefully separate the vessel from the base of the aneurysm. And you can really see where the aneurysm arises from its parent vessel, and then separating the dome of the aneurysm from the brainstem so that we can apply a clip. That's a little bit of a flow seal and then separating right brainstem separating sharply the brainstem from the dome of the aneurysm, one millimeter at a time until we get enough room here to be able to apply the clip. And very tedious a process because so much is at stake here. And they just keep going around it until we have the exposure necessary. And now using one dissection and we need to be able to get through there. Here's the neck of the aneurysm. And once we have enough room, I'm hurrying, I don't think he liked my move right there. So now you can see we really, we are getting the kind of room that we need in order to apply the times of the clip on each side of the neck, you can see how deep it is. You also see absolutely no need for a retractor because we don't need a lot of retraction of apply. But now we've created that space between the neck and the brainstem. And again, applying a mini clip across the neck of the aneurysm. And then naturally you wanna be sure we've maintained patency of the ICAs. And for that ICG green is just incredible. So utilizing the clip to separate it from the artery, so a little bit. There's the picture and you see an ICG green pass the clips, you see those vessels very nicely, Peyton. And pulse, you can see the aneurysm completely obliterated. This is a super cerebellar aneurysm. These are a straightforward of a battler tip kind of aneurysm. As you can get the superior cerebellar artery aneurysms, because there is a paucity of critical perforators. Opening the fissure, internal carotid artery, optic nerve around the right side. One of the tricks that I try to impart to the resses and fellows, you see a very large pecan here, is to follow the anteriortrovial. And by following the antiretroviral, you open the fissure widely, and here you get this beautiful view of the basil artery, contralateral basler artery, superior cerebellar artery. You're looking smack dab right at the aneurysm. See it right here. You see ipsilateral PCA on this side and then contralateral, that's the dome of the aneurysm SCA, PCA, and then just separating the space in order to create a neck, you can see it's a very white based aneurysm. So then as we apply the clip, we actually pull up a little bit as the tine stakehold. So we're sure we don't catch anything behind it. And then once we're very, we look back there, and there it's gone. Here's another one, a little bit of a different anatomy. Again, you see the SCA aneurysm. Opening the fissure widely, internal carotid artery. Sometimes you work between the optic nerve and the internal carotid artery. Most of the time in this space here now you're between those two vessels. I mean, between the optic nerve. Here are the perforators, antiretroviral artery coming off backwards, this is the other space. So you've got this space, and the one between anterior cerebral and middle cerebral artery. One of the tricks for the third nerve is to cut the iragmoid only on the side toward the aneurysm, not on the other side that keeps the third nerve nice and retract that. I don't remember the last third nerve policy that we have cost and treating a basil or tip or SCA aneurysm. I think you really don't manipulate it at all. That's post to your cragnoid that we're going over. That's in the way that can be drilled here. The tines of the clip are visible as they go down on the aneurysm. And again, I don't know whether you could tell, but I lifted up at the very end. So if there's anything behind it, it doesn't get caught in the times. And as you can see, when you move the clip aside, there are small branches on the brainstem, which we wanna make very, very sure that they are patent. We add on one little more clip for the remainder of the neck of the aneurysm toward us. Then we do an ICG and we look, and we can see all those little vessels behind the clip, all filling rapidly and appropriately. You can see these aneurysms are not particularly difficult. This is for a Ruptured Pica Aneurysm. It's a little more distal. It wasn't that clear on angiography, but a large hemorrhage, sort of a Far Lateral Approach, taking down part of the condyle and then allowing a put place to go in. And here you can see PICA lots and lots of blood. And if you look underneath the bipolars, you'll be able to see the aneurysm. I'm just removing the blood here, which we always try to do as long as it doesn't require a lot of manipulation of the tissues. But here you see PICA coming around and you can see the aneurysm right there, very straight forward, partially thrombose. But obviously that will bleed again as soon as that licese and a small little clip on the aneurysm eliminates the risk of that aneurysm causing any further trouble. And we wanna be sure that PICA is still intact. Then as you can see underneath the clip, it builds very nicely. That's for this aneurysm, we prepare the internal carotid artery. That's the radio artery that we're gonna use for the bypass. We used to do those endoscopically, but I think the trauma to the artery is actually greater than exposing it inside you, so we prefer doing that. The artery is full of pepper and then maintain that normal arterial pressure. The middle cerebral artery is exposed and then anastomosis between the radial artery and the middle cerebral artery is performed. And I think it really is important that the vascular neurosurgeon maintains these bypass skills because they often really come into play for those cases that we have no other solution for. And we need to be able to maintain that technique in our armamentarium. So you see the radial artery graft, which we then test for patency a good low that's because we haven't included the internal carotid artery yet. We enlarged the opening on the zygoma. We use this Argyle catheter, cut it lengthwise, put the vessel inside of it and then pass it to the neck wherever we anastomosis it. And we either use the internal carotid artery as we're doing in this case or the common or the external. The advantage of the interim was that it has a very nice diameter that is similar to the radial artery, cut it at an oblique angle, a wash out with heparin, and then utilizing 9/O sutures or 8/O sutures to Nasta malls. And if it's a tight vessel, then I use interrupted sutures like here to make sure there's no crimping. And whenever we do an ICG, we see nice filling of the bypass and the brain. Then we go down to where the aneurysm is and we apply a clip on the internal carotid artery in order to prevent any thrombus from the aneurysm getting... This is for Bilateral Middle Cerebral Artery Aneurysms. You see an aneurysm here, that's at the bifurcation. It's a young woman with a family history. I like fissure retractors, vein crossing the Sylvian fissure. And here you see the aneurysm that's coming off the internal carotid artery. Here the key is always to be able to see behind it so that we make sure we don't catch any of the perpetrators that are close by. And once we've done that, we decide, we go to the other side, just to see if we can reach the middle cerebral artery. And here we're opening the fissure on the contralateral side. And by opening that fissure, we determined whether it is reasonable to clip the contralateral middle cerebral artery, if it becomes visible. And I feel that I've got adequate control and we find this little aneurysm right here, which we hadn't really appreciated on the preoperative study. So we're coming across all the way across. That's the left middle cerebral artery and here's that aneurysm. And then we clip the bigger aneurysm. That'd be sound the perioperative study right on the middle cerebral artery bifurcation on the contralateral side. And then we clipped the aneurysm. That's probably the most threatening, which is at the internal carotid artery bifurcation. And you can see how you can use your sucker to pull in the edges to make sure that you're getting the neck as completely as possible. And then making sure that we haven't lost any vessels, still see the vein going across. And there's the post-op.

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