大脑中动脉瘤 CNS case 3

手术实例
#1

Pterional/Frontotemporal craniotomy for clipping of large unruptured MCA aneurysm

Overview

Complex clipping of broad neck Left MCA aneurysm with 2 large straight and 1 fenestrated clip.

Tandem use of clips to achieve complete aneurysmal obliteration.

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Case Presentation

  • 73-year-old, white female, independent for activities of daily living, who fainted in her bathroom, had a C2 fracture that was treated with a Cervical collar.
  • On CT of the head as part of her trauma work-up she was found to have unruptured left MCA and ICA aneurysms.
  • PAST MEDICAL HISTORY: Positive for hypothyroidism and breast cancer.
  • PAST SURGICAL HISTORY: Gastric bypass, tonsillectomy, hysterectomy, breast reduction, tummy tuck, bladder sling, blepharoplasty.
  • VITAL SIGNS: Weight 157 pounds, blood pressure 128/71, pulse 69, temperature 96.9.
  • GENERAL: Well developed, well nourished.
  • MENTAL STATUS: Awake, alert, and oriented. SPEECH: Fluent, good repetition, good understanding.
  • HEENT:
  • EXTREMITIES: No range of motion limitations. No contractures and no deformities.
  • MOTOR: 5/5 throughout.
  • TONE: No spasticity, no rigidity.
  • PROPRIOCEPTION: Normal throughout
  • CRANIAL NERVES: Normal
  • GAIT: Normal based, no ataxia.

Preoperative Arteriogram

Just distal to the ophthalmic artery origin there was multilobulated aneurysm measuring 5 mm in its maximum diameter.

Also Irregular 13.8 x 12.9 mm left MCA bifurcation aneurysm.

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Preoperative Angiogram

The ICA Aneurysm was treated by stent assisted coiling.

In the light of the fact that the left MCA aneurysm incorporated the inferior division of the left MCA within its neck.

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Approach

Left pterional craniotomy (link to pterional/frontotemporal craniotomy).

Positioning

Supine:
    Head rotated 30-45 degrees to the right fixed on three-pin fixation device (i.e.: Mayfield).
    Surgical area is saved (optional) and prepped in sterile fashion.

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Supine: Head rotated 30-45 degrees to the right fixed on three-pin fixation device (i.e.: Mayfield). Surgical area is saved (optional) and prepped in sterile fashion.

Incision

Starting a the level of the zygomatic arch just anterior to the tragus ( ~1 cm to avoid STA and frontal branch of Facial nerve).

    Extended in a curvilinear fashion supero-anteriorly towards the midline.

    Helpfull link: https://youtu.be/b4WFgifRjEw

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Soft Tissue Dissection

The skin is incised sharply starting anteriorly and directed towards the zygomatic arch.
The monopolar cautery or knife can be used to incise the galea. Hemostasis can be achieved with use of bipolar cautery and/or Raney clips. The temporalis muscle and periosteum is incised and retracted caudally to the zygomatic arch level.
Hooks are used to held the musculocutaneous flap.

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Bone

The bone is elevated with a pneumatic drill, multiple burr holes can be drilled to separate the dura from the internal table of the bone

Aggressive drilling of lesser wing of the sphenoid is performed to allow favorable microscopic dissection.

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Dura

  • The dura is opened in a curvilinear fashion with the base directed to the skull base
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    The frontal lobe is protected with Gelfoam and then with cotton strip.
    Subfrontally the optical carotid cistern is reached and opened,
    The optic apparatus is separated from the frontal lobe,
    CSF drainage facilitates brain relaxation

    The supraclinoid ICA is identified and dissected to reveal the takeoff of the middle cerebral artery.
    The Sylvian fissure is splittled from distal to proximal.
    The venous anatomy is “deciphered” intraoperatively.

SYLVIAN FISSURE OPENING
ALTERNATIVES:
    MEDIAL TRANSYLVIAN.
    TRANS-SUPERIOR TEMPORAL GYRUS

ANEURYSMAL DISECTION:

As the Sylvian fissure is completely disected
The dome of the aneurysm is revealed
Dissection of it from surrounding structures is carefully attempted, although mostly from the temporal lobe, this aneurysm was nearly impossible to dissect fully from the frontal lobe.
The planum temporalis is separated from the frontal lobe for visualization purposes.
The M1 is identified and dissected in preparation for temporary clip application.

The superior division of the MCA is separated from the dome of the aneurysm (this is achieved partially)
The proximal inferior division is also separated from the aneurysm
The aneurysm is also separated from the temporal lobe.



2 long aneurysm clips are used in a tandem fashion, one on each other, to close the aneurysm.
This is performed since after deployment of the first straight clip, the aneurysm continued to fill with each heart beat.
Moreover, it is noticed that there is a significant aneurysmal remnant ("dog ear") left towards the takeoff of the superior division. This is addressed with the use of a fenestrated clip, including on the fenestration the shaft of the long clips
The surgical field is verified to assure an undesired prepare of MCA or its branches has not occurred.


Post Op

Woke up without new deficits.
Discharged home after postoperative recovery
Postoperative Plain CT, CTA, Arteriogram.

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Pearls and Pitfalls

Complete obliteration of aneurysm may require multiple clips of different configuration.
Ideal positioning of the clip may lead to unadvertised arterial branches or the parent vessel.
Doppler or intraoperative angiography may revealed this in a timely manner.
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