Name: Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms (Video) | JoVE Journal
Uploaded: 2015-08-11T13:00:00.000+00:00
Duration: 11 min 58 s
Description: Learn minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms. This technique reduces hospital stays and costs while improving patient outcomes.

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5 minutes

The authors have no acknowledgments.

NOTE: Prior to performing this procedure, obtain all required institutional approval and patient consent.
1. Surgical Technique
<ol>
	<li>Induce patient with general anesthesia.</li>
	<li>Place radial arterial line for blood pressure monitoring.</li>
	<li>Place patient in the supine position on the operating room table.</li>
	<li>After the head is clamped into the Mayfield Head holder using standard techniques for a pterional craniotomy, position the head 30&#176;-45&#176; with the ipsilateral side up towards the ceiling, except for anterior-communicating artery aneurysms in which the head is placed at 60&#186; to allow for better visualization across the interhemispheric fissure.</li>
	<li>Position the neck midline and translate anteriorly to maximize jugular venous drainage to prevent cerebral edema and then extend the head to position the ipsilateral zygoma at the highest point&#8212;this allows for frontal lobe relaxation and elevation from the orbital roof during dissection without the use of retractors.</li>
	<li>Clip the hair in preparation for standard pterional scalp incision; use about a one to two inch strip behind the hairline.</li>
	<li>Sterilely prep the skin and drape the surgical area according to standard of care.</li>
	<li>Perform a standard curved scalp incision for a pterional approach extending from the midline of the scalp behind the hairline with a gentle curve posteriorly and inferiorly towards the tragus ending it about 3 mm anterior to the tragus and at the level of the superior edge of the zygoma. Perform this incision down to the skull above the superior temporal line and to the muscle fascia at the level of the temporalis muscle.</li>
	<li>Use electrocautery for scalp hemostasis with the bipolar device.</li>
	<li>Cut the temporalis muscle down to the skull using the bovie monopolar electrocautery device.</li>
	<li>Raise a myocutaneous flap keeping the temporalis muscle attached to the undersurface of the scalp for now. Fish-hooks are used to evert the flap after the temporalis muscle is elevated from the skull using a combination of monopolar electrocautery and a periosteal elevator.</li>
	<li>Perform an inverse subfascial dissection in the avascular plane from the undersurface of the myocutaneous flap using Metzenbaum scissors, keeping the fascia and subfacsial fat pad with the scalp to avoid injury to the facial nerve.</li>
	<li>Secure the temporalis muscle posteriorly and inferiorly to expose the pterional region with &#8220;star&#8221; fishhooks.</li>
	<li>Keep all components of the myocutaneous flap moist with wetted gauze.</li>
	<li>Drill a single temporal 5 mm burr-hole at the posterior-most aspect of the planned craniotomy with a 2 mm cutting burr so that the foot plate of the side-cutting drill can be inserted into this hole and then use a side-cutting drill with a foot plate to remove the thumb-sized (approximately 3 x 4 cm) kidney-shaped craniotomy centered anteriorly around the pterion.</li>
	<li>Using a No. 1 Penfield, separate the dura on all sides of the pterion and have an assistant gently retract the dura away from the bone surface that is being drilled to minimize risk of penetrating the dura and causing cortical injury.</li>
	<li>Remove the pterion with a drill: anteriorly, until the superior and lateral aspects of the orbital roof are smooth and flattened down to the outer cortical table of bone, without entering the orbit, to maximize subfrontal exposure; medially, drill until the superior orbital fissure dura is exposed and remove any small pieces of bone that would interfere with medial exposure using either a drill bit or hand-held Lempert bone cutting device. Ensure that excellent hemostasis of all soft-tissue and bone surfaces has been obtained to avoid blood dripping into the intradural space during brain dissection and aneurysm exposure, using electrocaurtery and bone wax as needed, before opening the dura.</li>
	<li>Gently elevate the dura and use a No. 11 scalpel to penetrate the dura and then use dural scissors to create a &#8220;C-shaped&#8221; opening in the dura with the base at the pterion. Secure the dura flat against the outer cortical bone of the orbit without having redundant dural leaflets that would otherwise obscure visualization of the proximal Sylvian Fissure and subfrontal region. This can be performed by using 4-0 Surgilons sutures to tack the dura to the scalp.</li>
</ol>
2. Brain Relaxation
<ol>
	<li>Give 25-50 g of Mannitol at the time of bone flap removal to relax the brain if anesthesia agrees that the blood pressure will tolerate diuresis. 
	NOTE: This will allow time for the diuresis to occur and ultimately will relax the brain to help maximize gravity dependent brain retraction during dissection.</li>
	<li>Keep End-Tidal pCO2 between 30-35 mm Hg to achieve slight hypercapnea. NOTE: This will safely allow for brain relaxation and maximize gravity dependent brain retraction during dissection.</li>
	<li>Evacuate cerebrospinal fluid (CSF) to promote brain relaxation by opening the arachnoid cisterns in the interoptic, carotid-optic, and carotid-oculomotor cisterns and patiently suction CSF until the desired brain relaxation has been achieved. 
	NOTE: This typically takes about 1 min; no lumbar drain is needed with this technique and it dramatically opens the surgical corridors.</li>
</ol>
3. Sylvian Fissure Dissection
<ol>
	<li>Bring the intra-operative microscope with the mouthpiece into the field using sterile techniques. Also bring surgical chairs with arm support into the field sterilely to maximize bimanual dexterity and to prevent surgeon arm and hand fatigue. 
	NOTE: The mouthpiece should be adjusted before draping so that the surgeon can move the microscope with the mouth while simultaneously looking through the ocular pieces.</li>
	<li>Perform dissection. 
	NOTE: For anterior communicating artery aneurysms, no Sylvian Fissure dissection is required and minimal (2-3 mm in extreme cases only, but this is a rare occurrence) to no gyrus rectus resection is needed using only subfrontal dissection; all other supraclinoid anterior circulation aneurysm locations (including posterior communicating artery) require &#60;1 cm proximal Sylivan Fissure dissection to expose the supraclinoid internal carotid artery, its branches (posterior communicating and anterior choroidal arteries), the internal carotid artery terminus, the A1 and M1 origins, and the proximal A2 and M2 segments distal to their respective bifurcations. Total Sylvian Fissure exposure was dime-size (1 cm x 1 cm) and no brain retractors were used for any of the cases reported. Gravity dependent brain relaxation was sufficient for excellent exposure of the soft tissue structures and vasculature needed to perform surgical clip ligation in the areas discussed above.</li>
	<li>Using bimanual manipulation with surgical microinstruments gently open the arachnoid corridors, holding the brain tissue aside with the edge of the instrument handles or suction device as needed through this exposure. 
	NOTE: The senior author&#39;s preference is to use a 4-French Fukishima suction tip in the non-dominant hand and in the dominant hand bipolar bayonettes for blunt dissection or microscissors for sharp dissection. Moistened Telfa strips are placed on the brain surface at the site of manipulation to prevent cortical injury. Cottonoids often stick to the brain surface and can&#8217;t be easily advanced deeper as the dissection progresses, without causing mild cortical injury.</li>
	<li>Use the mouthpiece on the operating microscope frequently to adjust the scope and focus length as needed while keeping both hands in the field.</li>
	<li>Secure the aneurysm in standard fashion, using the suction most often in the non-dominant hand to maintain the surgical corridor and visualization free of CSF.</li>
	<li>After clip placement, perform intra-operative Doppler of the aneurysm dome to confirm cessation of flow as well as the inflow and outflow vessels to confirm flow and carefully examine the aneurysm neck and parent vessels. We reserve intra-operative digital subtraction angiography (DSA) for anterior communicating artery aneurysms and those clipped aneurysms where inflow, outflow, or aneurysm neck cannot be visualized completely or there is a concern with intra-operative Doppler. Intra-operative DSA is preferred over indocyanine green (ICG) angiography because when multiple aneurysm clips are used to reconstruct the aneurysm neck, the clip can obstruct visualization. NOTE: Once the aneurysm has been securely clipped, the microscope is removed from the field and the brain irrigated with normal saline solution to minimize the amount of pneumocephalus after closure.</li>
	<li>After inspecting the clip for aneurysm occlusion with the Doppler, the aneurysm dome is perforated with a 22 G needle attached to intravenous tubing and a 10 ml syringe and manually suction aspirated to confirm aneurysm occlusion.</li>
	<li>Reapproximate the native dura with 4-0 surgilon and cover with a synthetic dural substitute if a watertight closure is not able to be obtained properly.</li>
	<li>Secure bone plates with a metal plating system per standard of care.</li>
	<li>Secure the frontal edge of the bone flap flush against the native bone to avoid space between the two which would not be cosmetically pleasing after the tissues heal.</li>
	<li>Reapproximate the temporalis muscle fascia with interrupted 2-0 Vicryl sutures. Secure the top of the temporalis muscle with a 2-0 Vicryl stitch to the frontal metal plate to reapproximate it to the superior temporal line.</li>
	<li>Reapproximate the galea using 3-0 Vicryl sutures and close the scalp in a standard fashion using either staples, nylon, or prolene. Dress with sterile bandages per surgeon preference.</li>
</ol>
4. Post-treatment Care
<ol>
	<li>Admit patient to the intensive care unit after treatment and mobilize with the nursing staff as soon as sedation or general anesthesia has worn off enough to do so, typically within 6 hr of extubation.</li>
	<li>Order physical and occupational therapy to begin post-operative day one in order to assess the patient for safe discharge to home if there were any concerns by the nursing staff.</li>
	<li>Discharge the patient when criteria are met: pain controlled with only oral medications, voiding independently, ambulating independently, and tolerating oral food intake.</li>
</ol>

<ol><li>Guglielmi, G., Viñuela, F., Dion, J., Duckwiler, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Electrothrombosis+of+saccular+aneurysms+via+endovascular+approach.+Part+2%3A+Preliminary+clinical+experience%5BTitle%5D)+AND+%22Journal+of+neurosurgery%22%5BJournal%5D)">Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience.</a> Journal of neurosurgery. 75 (1), 8-14 (1991).</li>
<li>Hoh, B. L., Chi, Y. -Y., Dermott, M. A., Lipori, P. J., Lewis, S. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+effect+of+coiling+versus+clipping+of+ruptured+and+unruptured+cerebral+aneurysms+on+length+of+stay%2C+hospital+cost%2C+hospital+reimbursement%2C+and+surgeon+reimbursement+at+the+university+of+Florida%5BTitle%5D)+AND+%22Neurosurgery%22%5BJournal%5D)">The effect of coiling versus clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the university of Florida.</a> Neurosurgery. 64 (4), 614-619 (2009).</li>
<li>Wiebers, D. O., Whisnant, J. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Unruptured+intracranial+aneurysms%3A+natural+history%2C+clinical+outcome%2C+and+risks+of+surgical+and+endovascular+treatment%5BTitle%5D)+AND+%22Lancet%22%5BJournal%5D)">Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment.</a> Lancet. 362 (9378), 103-110 (2003).</li>
<li>Molyneux, A., Kerr, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((International+Subarachnoid+Aneurysm+Trial+%28ISAT%29+of+neurosurgical+clipping+versus+endovascular+coiling+in+2143+patients+with+ruptured+intracranial+aneurysms%3A+a+randomised+trial%5BTitle%5D)+AND+%22Lancet%22%5BJournal%5D)">International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial.</a> Lancet. 360 (9342), 1267-1274 (2002).</li>
<li>Spetzler, R. F., McDougall, C. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+Barrow+Ruptured+Aneurysm+Trial%3A+3-year+results%5BTitle%5D)+AND+%22Journal+of+neurosurgery%22%5BJournal%5D)">The Barrow Ruptured Aneurysm Trial: 3-year results.</a> Journal of neurosurgery. , (2013).</li>
<li>Spetzler, R. F., Sanai, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+quiet+revolution%3A+retractorless+surgery+for+complex+vascular+and+skull+base+lesions%5BTitle%5D)+AND+%22Journal+of+neurosurgery%22%5BJournal%5D)">The quiet revolution: retractorless surgery for complex vascular and skull base lesions.</a> Journal of neurosurgery. 116 (2), 291–-300 (2012).</li>
<li>Chalouhi, N., Jabbour, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Surgical+treatment+of+ruptured+anterior+circulation+aneurysms%3A+comparison+of+pterional+and+supraorbital+keyhole+approaches%5BTitle%5D)+AND+%22Neurosurgery%22%5BJournal%5D)">Surgical treatment of ruptured anterior circulation aneurysms: comparison of pterional and supraorbital keyhole approaches.</a> Neurosurgery. 72 (3), 437-441 (2013).</li>
<li>Petraglia, A. L., Srinivasan, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Unilateral+subfrontal+approach+to+anterior+communicating+artery+aneurysms%3A+A+review+of+28+patients%5BTitle%5D)+AND+%22Surgical+neurology+international%22%5BJournal%5D)">Unilateral subfrontal approach to anterior communicating artery aneurysms: A review of 28 patients.</a> Surgical neurology international. 2, 124(2011).</li>
<li>Goettel, N., Chui, J., Venkatraghavan, L., Tymianski, M., Manninen, P. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Day+Surgery+Craniotomy+for+Unruptured+Cerebral+Aneurysms%3A+A+Single+Center+Experience%5BTitle%5D)+AND+%22Journal+of+neurosurgical+anesthesiology%22%5BJournal%5D)">Day Surgery Craniotomy for Unruptured Cerebral Aneurysms: A Single Center Experience.</a> Journal of neurosurgical anesthesiology. , (2013).</li>
<li>Andaluz, N., Zuccarello, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Recent+trends+in+the+treatment+of+cerebral+aneurysms%3A+analysis+of+a+nationwide+inpatient+database%5BTitle%5D)+AND+%22Journal+of+neurosurgery%22%5BJournal%5D)">Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database.</a> Journal of neurosurgery. 108 (6), 1163-1169 (2008).</li>
<li>Barker, F. G. 2nd, Amin-Hanjani, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Age-dependent+differences+in+short-term+outcome+after+surgical+or+endovascular+treatment+of+unruptured+intracranial+aneurysms+in+the+United+States%5BTitle%5D)+AND+%22Neurosurgery%22%5BJournal%5D)">Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States.</a> Neurosurgery. 54 (1), 18-28 (1996).</li>
<li>Cowan, J. A., Ziewacz, J., Dimick, J. B., Upchurch, G. R., Thompson, B. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Use+of+endovascular+coil+embolization+and+surgical+clip+occlusion+for+cerebral+artery+aneurysms%5BTitle%5D)+AND+%22Journal+of+neurosurgery%22%5BJournal%5D)">Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms.</a> Journal of neurosurgery. 107 (3), 530-535 (2007).</li>
<li>Crowley, R. W., Yeoh, H. K., Stukenborg, G. J., Ionescu, A. A., Kassell, N. F., Dumont, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Influence+of+weekend+versus+weekday+hospital+admission+on+mortality+following+subarachnoid+hemorrhage.+Clinical+article%5BTitle%5D)+AND+%22Journal+of+neurosurgery%22%5BJournal%5D)">Influence of weekend versus weekday hospital admission on mortality following subarachnoid hemorrhage. Clinical article.</a> Journal of neurosurgery. 111 (1), 60-66 (2009).</li>
<li>Hoh, B. L., Chi, Y. -Y., Lawson, M. F., Mocco, J., Barker, F. G. 2nd <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Length+of+stay+and+total+hospital+charges+of+clipping+versus+coiling+for+ruptured+and+unruptured+adult+cerebral+aneurysms+in+the+Nationwide+Inpatient+Sample+database+2002+to+2006%5BTitle%5D)+AND+%22Stroke%3B+a+journal+of+cerebral+circulation%22%5BJournal%5D)">Length of stay and total hospital charges of clipping versus coiling for ruptured and unruptured adult cerebral aneurysms in the Nationwide Inpatient Sample database 2002 to 2006.</a> Stroke; a journal of cerebral circulation. 41 (2), 337-342 (2010).</li>
<li>Hoh, B. L., Rabinov, J. D., Pryor, J. C., Carter, B. S., Barker, F. G. 2nd <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((In-hospital+morbidity+and+mortality+after+endovascular+treatment+of+unruptured+intracranial+aneurysms+in+the+United+States%2C+1996-2000%3A+effect+of+hospital+and+physician+volume%5BTitle%5D)+AND+%22AJNR.+American+journal+of+neuroradiology%22%5BJournal%5D)">In-hospital morbidity and mortality after endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000: effect of hospital and physician volume.</a> AJNR. American journal of neuroradiology. 24 (7), 1409-1420 (2003).</li>
<li>Shea, A. M., Reed, S. D., Curtis, L. H., Alexander, M. J., Villani, J. J., Schulman, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Characteristics+of+nontraumatic+subarachnoid+hemorrhage+in+the+United+States+in+2003%5BTitle%5D)+AND+%22Neurosurgery%22%5BJournal%5D)">Characteristics of nontraumatic subarachnoid hemorrhage in the United States in 2003.</a> Neurosurgery. 61 (6), 1131-1137 (2007).</li>
<li>Rodríguez-Hernández, A., Sughrue, M. E., Akhavan, S., Habdank-Kolaczkowski, J., Lawton, M. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Current+management+of+middle+cerebral+artery+aneurysms%3A+surgical+results+with+a+%E2%80%9Cclip+first%E2%80%9D+policy%5BTitle%5D)+AND+%22Neurosurgery%22%5BJournal%5D)">Current management of middle cerebral artery aneurysms: surgical results with a “clip first” policy.</a> Neurosurgery. 72 (3), 415-427 (2013).</li>
<li>Van Lindert, E., Perneczky, A., Fries, G., Pierangeli, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+supraorbital+keyhole+approach+to+supratentorial+aneurysms%3A+concept+and+technique%5BTitle%5D)+AND+%22Surgical+neurology%22%5BJournal%5D)">The supraorbital keyhole approach to supratentorial aneurysms: concept and technique.</a> Surgical neurology. 49 (5), 489-490 (1998).</li>
<li>Dott, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intracranial+aneurysms%3A+cerebral+arteriography%3Asurgical+treatment%5BTitle%5D)+AND+%22Edinb+Med+J%22%5BJournal%5D)">Intracranial aneurysms: cerebral arteriography:surgical treatment.</a> Edinb Med J. 40, 219-234 (1933).</li>
<li>Dandy, W. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Aneurysm+of+the+anterior+cerebral+artery%5BTitle%5D)+AND+%22Journal+of+the+American+Medical+Association%22%5BJournal%5D)">Aneurysm of the anterior cerebral artery.</a> Journal of the American Medical Association. 119 (16), 1253-1254 (1942).</li>
<li>Yasargil, M., Fox, J., Ray, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+operative+approach+to+aneurysms+of+the+anterior+communicating+artery%5BTitle%5D)+AND+%22Advances+and+Technical+Standards+in+Neurosurgery%22%5BJournal%5D)">The operative approach to aneurysms of the anterior communicating artery.</a> Advances and Technical Standards in Neurosurgery. 2, 113-170 (1975).</li>
<li>Al-Mefty, O., Fox, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Superolateral+orbital+exposure+and+reconstruction%5BTitle%5D)+AND+%22Surgical+neurology%22%5BJournal%5D)">Superolateral orbital exposure and reconstruction.</a> Surgical neurology. 23 (6), 609-613 (1985).</li>
<li>Heros, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+supraorbital+%E2%80%9Ckeyhole%E2%80%9D+approach%5BTitle%5D)+AND+%22Journal+of+neurosurgery%22%5BJournal%5D)">The supraorbital “keyhole” approach.</a> Journal of neurosurgery. 114 (3), 850-851 (2011).</li>
</ol>

Eric Deshaies is a physician consultant for MicroVention, Covidien Neurovascular, Integra LifeSciences Corporation.

Surgical clip ligation of intracranial aneurysms remains a relevant and important option in treating certain types of aneurysms, though this role has been diminishing over the past several years as endovascular technology becomes safer and more efficacious. Endovascular treatment has surpassed surgery for cerebral aneurysms, yet the higher recurrence rate after endovascular treatment, the occasional need for surgical treatment after aneurysm recurrence from failed endovascular treatment, specific morphologies making endo...

Surgical clip ligation had been the mainstay of treatment for intracranial aneurysms but has been recently supplanted mostly by less invasive endovascular techniques.1,2 Clinical trials including the International Study of Unruptured Intracranial Aneurysms (ISUIA-1 and ISUIA-2), and the International Subarachnoid Aneurysm Trial (ISAT) have demonstrated lower morbidity and mortality, reduced length of hospital stay, and lower overall expense, with endovascular treatment compared to surgical clip ligation.3&#8211;5 However, the higher aneurysm recurrence rate after endovascular therapy has led to the examination of the cumulative risk to the patients compared to surgical clip ligation.3,4 Surgical treatment remains an important modality for aneurysm therapy, particularly for anterior circulation aneurysms that have morphologies that may be difficult to treat with endovascular means.
Unlike advancements in endovascular devices, few advances in surgical techniques have been made recently. Techniques to make surgical treatment less invasive have included the supraorbital craniotomy combined with the eyebrow incision for anterior circulation aneurysms and &#8220;retractorless surgery&#8221; to minimize surgical trauma to the brain during aneurysm clipping.6&#8211;8 These less invasive surgical approaches may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes.9
Here, we present our experience with a minimally invasive approach to surgical clip ligation of unruptured intracranial aneurysms using a pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an age matched dataset from the Nationwide Inpatient Sample (NIS). The surgical technique will be reviewed, including patient preparation, brain relaxation, sylvian fissure dissection, and closure. Post-operative care and discharge requirements will also be outlined.

<table><tbody><tr><td>Mayfield Infinity skull clamp</td><td>Integra</td><td>A-1114</td><td></td></tr><tr><td>Mayfield table attachment</td><td>Integra</td><td>A-1018</td><td></td></tr><tr><td>4-French Fukishima suction tip</td><td>Integra</td><td>R-8986</td><td></td></tr><tr><td>Periosteal elevator (Langenbeck)</td><td>Codman</td><td>65-1116</td><td></td></tr><tr><td>Metzenbaum scissors</td><td>Codman</td><td>36-5023</td><td></td></tr><tr><td>Malis dissector, round angled</td><td>Codman</td><td>80-1541&amp;nbsp;</td><td></td></tr><tr><td>Penfield dissector, style 1</td><td>Codman</td><td>65-1015</td><td></td></tr><tr><td>Lempert bone rongeur</td><td>Codman</td><td>19-1232</td><td></td></tr><tr><td>Malis Irrigation Module</td><td>Codman</td><td>Module 1000</td><td></td></tr><tr><td>Bovie monopolar electrocautery device</td><td>Codman</td><td></td><td></td></tr><tr><td>Insulated blade for electrocautery device</td><td>Covidien</td><td>E1455</td><td></td></tr><tr><td>Fish-hook retractors</td><td>Lone Star</td><td>3350-8G</td><td></td></tr><tr><td>Pneumatic drill</td><td>Medtronic</td><td>Midas Rex MR7</td><td></td></tr><tr><td>Side-cutting drill</td><td>Medtronic</td><td>F2/8TA23</td><td></td></tr><tr><td>Fluted legend match head tool</td><td>Medtronic</td><td>10MH30</td><td></td></tr><tr><td>Surgical scalpel No. 10, 11, 15</td><td>Bard-Parker</td><td>0029064 (No.10), 0018291 (No.11), 0018043 (No.15)</td><td></td></tr><tr><td>Intra-operative microscope with mouthpiece</td><td>Leica</td><td></td><td></td></tr><tr><td>Microscissors</td><td>V. Mueller</td><td>NL3785-034(st), NL3785-035(cvd)</td><td></td></tr><tr><td>Rhoton dissector, #2</td><td>V. Mueller</td><td>NL3785-002&amp;nbsp;</td><td></td></tr><tr><td>Telfa strips</td><td>American Surgical</td><td>#80-09 (1/2x3), #80-04 (1/4x3)</td><td></td></tr><tr><td>Aneurysm clip</td><td>Aesculap</td><td></td><td></td></tr><tr><td>Raney clip applier</td><td>Aesculap</td><td>FF012R</td><td></td></tr><tr><td>Synthes Matrix metal plating system</td><td>Synthes</td><td></td><td></td></tr><tr><td>Braided absorbable surgical sutures (Vicyrl)&amp;nbsp;</td><td>Ethicon</td><td>J790D (3-0), J743D (4-0)</td><td></td></tr><tr><td>Braided nylon nonabsorbable surgical sutures (Nurolon) 4-0</td><td>Ethicon</td><td>C584D</td><td></td></tr><tr><td>Doppler System</td><td>Mizuho</td><td>07-150-02</td><td></td></tr></tbody></table>

minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients &#8804;55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged &#8804;55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Currently, at our institution over 150 aneurysms are treated annually. From August 2008 to December 2012, 22 elective aneurysm clippings using this minimally invasive thumb-sized pterional craniotomy technique for supraclinoidal aneurysms on patient&#8217;s &#8804;55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon that developed this technique (EMD) (Table 1). This age group was chosen as earlier trials have shown that surgical treatment of aneury...

Minimally invasive thumb-sized pterional craniotomy for aneurysm clipping has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

The overall goal of this procedure is to isolate an intracranial aneurysm from the normal circulation by a surgical clip ligation, using a less invasive surgical approach. This is accomplished by first prepping the patient in a Mayfield head holder and then dissecting the scalp to ultimately expose the ion. The second step of the procedure is to drill and remove a thumb sized craniotomy centered around the ion.The third step is to reach the aneurysm by a bimanual dissection of the sylvan fissure without the use of brain retractors, and then secure the aneurysm. The final step is to use intraoperative doppler of the aneurysm dome and surrounding vessels to confirm normal circulation before performing. A standard closing use of this protocol can result in shorter hospital stays at lower costs and fewer complications than the national average.The main advantage of this technique over existing techniques like the standard TER onal craniotomy, is that patients can have shorter hospital stay at a lower cost Position the head and neck for maximal venous drainage with the ipsilateral zygoma positioned at the highest point, expose and sterilize the dermis and drape the surgical area. Begin the surgery with a standard curved scalp incision for a AL approach extending from the midline of the scalp behind the hairline. Gently curve the incision towards the tragus.Complete the incision three millimeters anterior to the tragus level. With the superior edge of the zygoma above the superior temporal line, the incision should penetrate to the skull and at the level of the temporalis muscle, the incision should penetrate to the muscle facia. Use bipolar electrocautery to acquire scalp homeostasis as needed.Next, with a Bovie monopolar electrocautery device, cut the temporalis muscle down to the skull directly beneath the scalp incision. Now raise a myocutaneous flap anteriorly using a periosteal elevator and use electrocautery to elevate the temporalis muscle. Then using fish hooks avert and secure the myocutaneous flap starting at the undersurface of the flap.Use metson balm scissors to make an inverse subfascial dissection in the vascular plane. Keep the facia and sub fat pad attached to the scalp to avoid injuring the frontalis branch of the facial nerve. Use starfish hooks to secure the temporalis muscle posteriorly and inferiorly exposing the AL region going forward.It is important to always keep the entire scalp flap and temporalis muscle moist with wet GREs. Using the drill, make a three to four millimeter bur hole of the most inferior temporal location of the planned craniotomy. Using a two milliliter cutting bur to start the hole, then use the foot plate of a side cutting drill to widen out the hole into a thumb sized craniotomy about three by four centimeters based around the ion.Drill out the ion to complete the craniotomy and save the bone flat. Use a number one Penfield to separate the dura from the lateral sphenoid wing. An assistant must gently retract the dura away from the bone wall drilling so the dura is not injured with the drill in the next step.Now use the two millimeter burr to drill out the lateral sphenoid wing and the superior and lateral orbital walls until only the outer cortical table of bone remains. Do not enter the orbit medially drill until the lateral aspect of the superior orbital bone fisure is exposed. Is the drill or a handheld lepert bone cutter to remove any small pieces of bone that would interfere with medial exposure after they're dissected from the dura?Now, before opening the dura, use bipolar electrocautery and bone wax to ensure excellent hemostasis of all the soft tissue and bone surfaces. This will prevent blood from oozing into the intradural space and hindering visualization. Gently elevate the dura and open using a number 15 scalpel.Using dural scissors, create a CS shaped opening from the frontal dura extending inferiorly to the temporal dura with the base of the dural flap opening centered around the tarion. Using four zero sutures, take the dura to the soft tissues more superficially, making sure that the dural flap lies flat against the alter cortical bone of the orbit. Do not let the dural flap obscure the view of the proximal sylvan fissure or the sub frontal region.We suggest using a six French Fukushima suction tip for the superficial sylvan fissure dissection in a four French Fukushima suction tip for the deeper dissection around the optic nerve, the arteries, and the aneurysm itself. These tips have good suction strength and can easily be adjusted with the thumb during dissection. Hold the suction in the non-dominant hand in the bipolar device or micro dissecting instruments in the dominant hand.Then make certain the surgeon's forearms are resting comfortably at the desired height to minimize upper body fatigue. Initially, the surgeon's hand will have a projection nearly parallel to the floor during a superficial dissection of the sylvan fissure. Later, the hands turn more perpendicular to the plane of the floor as the dissection deepens into the sylvan fissure.Throughout this angle, change the flat edges of the instruments are able to maintain gentle retraction as needed. Now, LA moist telfa strips on the brain surface perpendicular to the sylvan fissure at the site of manipulation, so they follow the angle of the retraction instrument and the telfa do not obscure the fissures content. Using the telfa strips to stabilize the instruments edges start the next phase of the surgery.First, further relax the brain evacuate the cerebral spinal fluid by opening the YL vian fissure and the three arachnoid sters, the inter optic, carotid optic and carotid ocular motor. With these subarachnoid spaces opened patiently suction the cerebral spinal fluid. This avoids having to place a lumbar drain in the patient preoperatively.Then to open the arachnoid corridors, gently hold the brain tissue aside with the edge of the instrument handles or with a suction device. Now perform the sylvan fissure dissection less than one centimeter. Proximal YL and fissure dissection is required to expose the internal carotid artery terminus, the posterior communicating and anterior choroidal arteries, the A one and M1 origins and the proximal A two and M two segments for aneurysms.Other than of the anterior communicating region, the Sylvan fisheries dissected about one centimeter posterior to its anterior most extent. To expose the supra glenoid ICA, its branches, the A one and M1 origins and the A two and M two segments. In the case of anterior communicating artery aneurysms, Sylvan fisher dissection is rarely required, and little to minimal gyrus rectus resection is needed.Depending on how high the anterior communicating segment is positioned. Sub frontal dissection underneath the frontal lobes alone is usually adequate to access the anterior communicating region. Once proximal and distal controller obtained, the aneurysm is identified and dissected out from surrounding structures.It can be secured in the standard fashion using the four French Fukushima tip to maintain mild retraction and optimize visualization during clip application. After clipping the aneurysm, perform an intraoperative doppler of the aneurysm dome to confirm cessation of flow. Also, check the inflow and outflow zones to confirm patency.Once the occlusion is confirmed, acquire excellent hemostasis and prepare for closure. Re approximate the native dura with four zero sillon and cover with a synthetic dural substitute. If a watertight closure is not able to be obtained adequately secure the bone plate with a metal plating system per standard of care first, but the frontal edge of the bone flap flush to the native bone, so there will be no unsightly space between the two plates after healing.Depending on the residual bony defect, a small wire meash can be contoured and secured behind the orbit to reconstruct the terone region. Next, re approximate the temporalis muscle fascia posteriorly with interrupted two zero vicral sutures and superiorly to the frontal metal plate. Secure it anteriorly minimizes cosmetic defect anteriorly.When temporalis muscle atrophy occurs, then rear approximate the G using three zero Vicryl sutures and lastly, close the scalp in a standard fashion using either staples or sutures. In 22 elective aneurysm clippings on patients less than 55 years of age performed by the developer of the technique, only one patient who had a right MCA aneurysm experienced postoperative complications. In 18 patients follow-up imaging showed no occurrences through an average duration of 22 months.Compared to the nationwide inpatient sample data, the hospital stay and expenses for such patients undergoing the procedure from 2008 to 2010 was significantly reduced non-inclusive of patients with subarachnoid or intra cerebral hemorrhage. After watching this video, you should have a good understanding of how to isolate an intracranial aneurysm from the normal circulation via surgical clip ligation using a less invasive surgical approach. Thank you for watching this video.

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Learn minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms. This technique reduces hospital stays and costs while improving patient outcomes.

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

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