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Michigan Peter A. Maryland Russell Reid. Ohio Sharad Rajpal.
Anderson Cancer Center Houston. Maryland Daniel K. Illinois Violette Renard Recinos. New York Ganesh Rao. Florida Dimitris G. Ohio David Pincus. Texas Rakesh Patel. Maryland Charles J. Wisconsin Alfredo Quinones-Hinojosa. Wisconsin Charles J. MD Chairman of Neurosurgery St. Massachusetts Amer F. Washington Harshpal Singh. Belgium R. Maryland Michal A. Georgia Andrew C.
Texas Johannes Schramm. New York Nader Sanai. Florida Daniel L. Michael Scott. Germany Thomas C. Ohio Gerald E.
MD Spine Surgeon. California David I. MD Assistant Professor of Neurosurgery. Contributors Howard A. Long Hospital Atlanta.
Orthopedic Surgery. Pennsylvania Chandranath Sen. New York Andrew J. FACS President. Virginia Theodore H. New York Guy Rosenthal. Texas xxxi Raymond Sawaya. MD Arthur A. California Daniel Sciubba. New York B. Minnesota Robert M. California Phillip B. Virginia Michael E. MD Professor of Neurosurgery. New York Arien Smith. Boston Boston. Virginia Michael P. Pennsylvania Brian R.
Massachusetts Volker K.
Arizona Robert J. Gregory Thompson. Pennsylvania Shirley I. California Omar N. Michigan Luis M. Ohio Michael F. Radiation Oncology. Texas Nirit Weiss. Washington K. New York Christopher J. California Hasan Zaidi. California Kevin Walter. Michael Webb. California James Waldron. Wisconsin Mario Zuccarello.
California Albert J. Massachusetts Gabriel Zada. Maryland Thomas A. New York Arthur A. Contributors Fernando Vinuela. Union City.
Center Valley. Wilson frame Mizuho OSI. Yasargil Leyla bar attachment Aesculap. Approaches Positioning — Check operating room OR table set-up prior to transferring patient. If you slowly run through these items and their respective role in the case when entering the OR. There are 11 elements: Ensuring that the entire OR team understands the case. Understanding the procedure. Budde Halo Integra. FL Bipolar cautery irrigating bipolar optional Microscope Monitors for frameless stereotactic navigation Anesthetic Issues — Preoperative intravenous IV antibiotics administered within 30 minutes prior to incision — For most procedures: Gelfoam [Pfizer.
Surgicel [Ethicon. Greenberg Codman. Stealth [Medtronic. CT scrub for 5 minutes — Area is dried with sterile towel. MA gauze placed in external auditory canal to prevent prep fluid accumulation — Betadine Purdue Pharma.
If prone position. Woodson dissector. Approaches — Incision is marked — DuraPrep 3M. Epidural hemostasis is achieved by controlling dural bleeding with bipolar cautery. Closure of Dura — Closure of dura proceeds after hemostasis of operative field has been ensured — The dura is reapproximated with interrupted or running 4—0 Nurolon sutures while avoiding injury to cortical vessels or draining veins — If watertight dural closure cannot be obtained: The dura is tacked up to the craniotomy edges with 4—0 Nurolon sutures Ethicon to close the epidural space and prevent epidural hematoma formation.
Two small holes are placed in bone flap in anticipation of a central dural tacking suture during closure. Holes are drilled at an angle in the native skull along the edges of the craniotomy for dural tack-up sutures. Irrigation is performed to remove bone dust and identify sites of bone or dural bleeding.
Gelfoam or FloSeal Baxter. Opening of Dura — Using fine-toothed forceps or a 4—0 Nurolon suture to lift the dura.
Approaches — — — — — — — — Central dural tack-up suture is threaded through bone flap Bone flap secured with titanium miniplates and screws Central dural tack-up suture is tied to close epidural space Bone filler to obliterate bone defects is optional Subgaleal drain is optional Muscle and fascial layers are closed with 0 or 3—0 Vicryl Ethicon sutures Galea closed with inverted 3—0 Vicryl sutures Skin closed with staples.
It is important to insert the endoscope into the introducer expeditiously to prevent the rapid egress of CSF that may result in postoperative subdural hematomas. It is easiest to use written text such as the labeling on the outside of a sterile suture box or marking pen. Introduction of Endoscope — The dura is opened and the dural leaflets are coagulated with bipolar cautery. Intraventricular Anatomy — Identify the following landmarks in the lateral ventricle: A mark at 5 cm is placed to avoid deeper penetration.
Stereotaxy can also be used to reorient oneself. Other causes include turbid CSF. In the majority of cases. If significant bleeding occurs. Aggressive ventricular drainage. Techniques — If the image is blurred look for technical problems: Management Pearls — Eyes on monitor at all times when endoscope is intracranial — Abort procedure if visualization or anatomy is impaired. In cases with continued bleeding. This can be relieved by stopping irrigation and removing the endoscope to allow the egress of irrigation fluid and CSF.
Complications — In cases of significant bleeding it is important to irrigate copiously until hemostasis is achieved. Once hypertension and bradycardia have resolved the procedure can be resumed with more cautious irrigation. For an anterior interhemispheric approach. Burr holes spanning across the superior sagittal sinus are created at the anterior and posterior edges of the bone flap B. Opening of Dura — Dura can be opened in a cruciate manner with intersecting incisions if necessary.
Prepare in advance to control bleeding from superior sagittal sinus with Gelfoam of appropriate size. B Burr hole locations and craniotomy. A small chisel or narrow side cutting burr may be used to release the nerve if a true foramen is present. Place miniplates along the flap prior to elevation to ensure a good cosmetic closure. Approaches Surgical Approach Phase I: Frontosphenotemporal Pterional Craniotomy Fig.
The muscle is separated with blunt dissection. Orbitozygomatic Osteotomy Fig. Stay above the zygomaticofacial fissure to avoid the maxillary sinus. Oblique cuts are made for cosmetically appealing reapproximation. The supraorbital nerve is easily reflected with the periorbita if a supraorbital notch is present. Five cuts B are made in the zygomatic process.
Approaches Closure — Reapproximation of the dura — Placement of pericranium with its vascular pedicle in cases of a violated frontal sinus — Gelfoam is placed over the dura. Avoid cautery so as to minimize nerve injury. Bone over the optic foramen is preserved during this portion of the procedure.
B Extradural drilling of the optic strut and anterior clinoid process. Note that the subtemporal exposure at this junction will aid in the exposure of the posterior aspects of the cavernous sinus and allow for identification of the third and fourth nerves. General Craniotomy Techniques Incision — Depending on size of craniotomy. Debulking of tumor allows rotation to cauterize choroidal arteries. Minimize intraventricular hemostatic products. Approaches Complications Perioperative — Injury to superior sagittal sinus or draining veins — Injury to sensorimotor cortex or superior parietal lobule — Injury to optic radiations Postoperative — — — — — Seizures Venous infarction Wound or flap infections Visual field deficit Parietal lobe dysfunction Management Pearls — The patient should be positioned so that the trajectory to the lesion is vertical.
Approaches Postoperative — Steroids if appropriate — Antibiotics continued for 24 hours — Compression stockings. Sterile Scrub and Prep — See Chapter 2. Access to the right lateral ventricle after inadvertent entry into the left lateral ventricle is accomplished by further lateral resection of the corpus callosum or fenestration of the septum pellucidum.
Approaches Entry into the Lateral Ventricle — The cauterized ependymal layer is opened for entry into the lateral ventricle — The brain retractor is repositioned just beyond the inferior callosal margin — Orientation of entry into either the right or left lateral ventricle is confirmed by the configuration of the choroid plexus and thalamostriate vein.
Franklin Lakes. Keep them wet with Telfa strips and unstretched. Further interhemispheric space can be obtained by microsurgical dissection of the veins along their bridging course. NJ can be prepared to rapidly stem bleeding in the event of sinus injury.
Bruce Indications — — — — — — Petroclival tumors Large. Mandigo and Jeffrey N. Holes are drilled for tenting sutures. The transverse sinus is freed and additional craniotomy is performed infratentorially if necessary. Approaches Division of the Tentorium — Retraction of temporal lobe is performed with the aid of the operating microscope using the advancement of Bicol. Greenberg retractor blades. The division of the tentorium is carried in an anterolateral direction into the middle fossa and across the superior petrosal sinus with suture ligatures or titanium clips.
Surgical Treatment of Cortical Arteriovenous Malformations. Temporal Glioma — Vascular malformation see Chapter Approaches — Dexamethasone 10 mg IV prior to incision — Mannitol 0. Steri-Drape 3M. NC on superficial temporal artery prior to cutting it with knife — Temporalis fascia incised with knife and extended with Metzenbaum scissors. Research Triangle Park. Pterional Approach Horseshoe shaped with base over sphenoid Started at inferior extent of temporal lobe limb of incision 4—0 silk through outer leaf of dura to elevate.
General Craniotomy Techniques Complications Perioperative — — — — — Cervical spine injury from excessive head turning Dural tear Cortical injury with craniotome CSF leak from inadequate waxing of anterior mastoid air cells Peripheral cranial nerve VII palsy from incision. Drainage is from the sylvian veins into the sphenoparietal sinus. When large anterior temporal resections are undertaken.
Approaches — Neurophysiologic monitoring: The flap is reflected anteriorly to the level of the external auditory canal and held in place with suture or self retaining hooks. B dural opening. The translabyrinthine approach is used if there is preoperative ipsilateral deafness. The facial canal remains protected by bone in both exposures.
In the retrolabyrinthine approach. Bony Opening — Combination of cutting and diamond burrs is used to drill the posterior petrous bone — The retrolabyrinthine approach is used if preoperative hearing is present. The endolymphatic sac is unroofed and preserved. CN XI Fig. Sinus pressure must be measured intraoperatively to determine the competence of the torcula prior to this maneuver. The dural closure should be augmented with fibrin glue or other dural sealant and a free fat graft obtained from the abdomen or thigh.
Intradural — The lateral cerebellomedullary cistern is entered sharply for CSF drainage and brain relaxation — Sharp arachnoid dissection is performed to decrease tension on CNs during manipulation Dural Closure — Every attempt should be made to create a watertight seal.
Approaches — The distal transverse and sigmoid sinuses are skeletonized to the level of the jugular bulb — The superior petrosal sinus is skeletonized — Subtemporal. The mastoid antrum must be obliterated with bone wax with care taken not to disrupt the ossicles in a hearing preservation approach.
This can only be performed in a nondominant or occluded sinus.
Titanium Mesh Cranioplasty — Titanium mesh should be conformed appropriately and secured in place over the cranial defect Soft Tissue Closure — The temporalis and sternocleidomastoid muscles are reattached at their common myofascial cuff. Sisti Indications — — — — — Progressive hearing loss or recent.
CN VII. Intraoperative Monitoring — Surgical dissection and resection are assisted by electrophysiological monitoring of CN V. Approaches — After originating at the basilar artery. This can be followed over time with serial magnetic resonance imaging. Craniotomy and bony opening A.
C1 arch. The jugular process has an indentation anteriorly at the site of the jugular notch. Approaches Complications Intraoperative — Vertebral artery: The facial nerve exits the stylomastoid foramen just lateral to the jugular foramen.
Bruce Indications — Lesions of pineal region especially midline — Dorsal midbrain lesions e.. Approaches Closure — — — — — — — Hemostasis crucial. Bruce Indication — — — — Mass lesions of the occipital lobe Posterior falcine meningiomas Tentorial meningiomas with only supratentorial component Tumors of the pineal region..
Ricardo J. Approaches Special Equipment — — — — — Operating microscope optional Mayfield head holder Frameless stereotaxy Yasargil bar and Greenberg retractors Cavitron Anesthetic Issues — Communicate degree of intracranial pressure elevation to anesthesiologist — Arterial line blood pressure monitoring — Intravenous IV antibiotics with skin flora coverage oxacillin 2 g should be given 30 minutes prior to incision — Dexamethasone 10 mg IV prior to incision — Mannitol B Microscopic view following division of the falx and tentorium.
Penfield no. Burr holes should be placed over sagittal sinus to avoid craniotome injury. Approaches — In general. This is best seen on axial imaging and provides important intraoperative correlation. All patients should be evaluated by an endocrinologist prior to surgery.
Equipment — — — — Transsphenoidal tray Optional: Paul T. A narrow intercarotid aperture should prompt caution and a narrow initial dural opening. This will be needed for the immediate postoperative visual assessment. Tumors with a significant hourglass appearance may benefit from lumbar drain insertion for air insufflation during surgery.
The normal gland will enhance more brightly than the tumor and the remaining normal gland should be ipsilateral to the side of stalk deviation. Imaging also delineates the superior and inferior limits of the sella turcica. These should be continued postoperatively if nasal packing is placed and can be discontinued when the nasal packing is removed.
No tape should be placed across the upper lip. The bridge of the nose should be parallel to the floor. Place after intubation and connect to a closed drainage system. This modality is most appropriate for repeat transsphenoidal surgery. Videofluoroscopy may also be used for an encephalogram to confirm the resection of the suprasellar tumor after instillation of air via a lumbar drain.
Anesthetic Issues — Blood pressure monitoring. The assistant oculars should be set to the left of the primary surgeon. The bed is then placed diagonally in the operating. Do not drain cerebrospinal fluid CSF during the operation.
Adult patients undergoing first time transsphenoidal surgery who have good quality nasal tissue especially acromegalics in whom a wide exposure is desired. The operating table is tilted slightly toward the surgeon.
Displace the cartilaginous septum into the left nasal cavity. Cleanse the nose and mouth with chlorhexidine. Sublabial Transseptal Approach — Indications: Pediatric patients. Develop bilateral inferior submucosal tunnels along the nasal floor and detach the cartilaginous septum from the anterior nasal spine. This approach provides a rapid exposure of the sphenoid sinus but is narrower than the transseptal approach. Submucosal Tunnels — Ipsilateral submucosal tunnels: Using a Cottle or Freer dissector.
Inject the septal mucosa subperichondrially with 0. Using a blade knife in the right nostril. Identify the junction of the cartilaginous and bony septum. Using the blades of the speculum. Develop a posterior submucosal tunnel along the contralateral bony septum toward the sphenoid rostrum. This bone is saved for sellar reconstruction at the end of the operation. Avoid liberal use of Bovie cautery to prevent thermal injury to the teeth. Separate the cartilaginous septum along its attachment to the bony septum and then along the maxillary ridge.
Adult patients undergoing extended microscopic skull base approaches. The trajectory is also slightly off midline and exposes more of the contralateral side of the sella. Using Knight scissors and a large pituitary rongeur.
Adult patients undergoing repeat transsphenoidal surgery or first time transsphenoidal surgery in patients with poor quality nasal tissue especially patients with Cushing disease. A cuff of mucosa must remain attached to the gingiva to permit closure at the end of the operation. Use the 4-mm outer diameter.
Expose the contralateral sphenoid ostium and resect the sphenoid bone between the two ostia. This requires removal of intersphenoid sinus septae. Find the sphenoid ostium posterior to the superior turbinate. Adult patients undergoing transsphenoidal surgery — Although this is a binasal operation. Sphenoidotomy and Sellar Exposure — If performing a transseptal approach.
Displace the posterior septum from the sphenoid rostrum and retract the septum with both layers of mucosa attached into the contralateral nasal cavity. Obtain a videofluoroscopic image to confirm the appropriate trajectory to the sphenoid sinus.
Approaches — Place a long nasal speculum in the right nostril along the middle turbinate with the tips approximated 1. Do not resect the posterior septum more anteriorly than the anterior limit of the middle turbinate. Elevate the mucosa overlying the sphenoid sinus bilaterally to expose both sphenoid ostia. Endoscopic Binasal 3. Ensure that the posterior septectomy is complete.
Reconstruct the sellar floor using either harvested septal bone or a synthetic material. Closure — Irrigate the tumor cavity with saline. Soak the tailored pieces of fat in antibiotic solution and then dab them in cotton and Avitene. Large defects in the diaphragma sellae also require obliteration of the sphenoid sinus with fat. Initially debulk the inferior portions of the tumor. Remove a patch of dura when resecting macroadenomas so that the specimen can be sent to pathology to determine the presence of tumor invasion.
Removal of Tumor — Using a blunt nerve hook. Place the fat grafts into the tumor bed and reconstruct the sellar floor. If the intercarotid distance is narrow. Dural Opening — Prior to opening the dura.
Identify the location of the normal gland if discernible and determine the intercarotid distance at the level of the cavernous sinus. Care should be taken to only traverse the dura and to not enter the gland or tumor. If a narrow interval is present. A cruciate incision is made when removing microadenomas. Suction the stomach using the preoperatively placed orogastric tube. Greater than mL of urine output for 3 consecutive hours should prompt an evaluation.
Remove the speculum and irrigate the nasal cavity. If imaging suggests overpacking. Complications Perioperative — Nasal: Anterior septal perforations. Most often not a difficult diagnosis. If persistent. May be secondary to overpacking of the sella. Treat diabetes insipidus acutely with intravenous or subcutaneous desmopressin. Irrigate the nasal cavities and inspect around the inferolateral corners of the sphenoidotomy for bleeding. Place nasal rockets between the middle turbinates and the nasal septum.
Draw the serum cortisol level at 6 AM on postoperative day 2 and 3. If not adrenally insufficient preoperatively. No nasal rockets are required.
Remove the speculum. Injury to the cavernous carotid artery or cavernous cranial nerves. Medialize the ipsilateral middle turbinate and reposition the nasal septum in the midline. Medialize the middle turbinates bilaterally. In cases in which uncertainty persists one may perform Tau transferrin. Patients who are adrenally insufficient preoperatively should be continued on steroids postoperatively. Close the hemitransfixion incision and the sublabial incision if present using absorbable chromic suture.
Strict fluid input and output measurements. A confirmed postoperative CSF leak is effectively treated by return to the operating room for repacking of the sella and sphenoid sinus. A thorough endocrinological evaluation should be performed prior to surgical consideration. Similar consideration should be given to access for abdominal fat.
Leaving the scalp too thin will lead to wound breakdown postoperatively as well as result in excess epidural tissue compressing the brain under the cranioplasty flap. Minimal Shave — Use electric clippers — Expose prior incision with 2-cm strip as well as any extension of prior incision — Slick hair bordering incision down with antibiotic ointment bacitracin. Muscle and Soft Tissue Dissection — Should be approached in the same way the initial dissection was done to avoid unduly devascularizing the muscle tissue — For a cranioplasty.
Opening the entire incision will give full access to the underlying bone flap and speed removal. Puncturing the dura during the dissection can cause brain injury. These sites can be best anticipated based on a careful review of a preoperative CT.
General Craniotomy Techniques Incision — In most operations. A water tight seal on the dura is critical as healing of superficial tissues may be retarded. In these cases. Expect dural defects. IN] and no. The original suture line may be used for reoperations done shortly after the original operation. Dura Opening — The dura will be most adherent to the brain at any prior suture lines. Closure — Use 4—0 silk suture to close dura. Craniotomy — Depending on the interval between the initial craniotomy and reoperation.
Often original plates may be reused safely and successfully. Areas where skull has fused to prior bone flap should be cut with a high-speed drill large or Kerrison punch small.
Synthetic graft materials are available. For reoperative craniotomies performed at an extended time after the original operation.
Approaches — In cases of infection. Moving your dural opening over as little as 0. Knowing what cranial fixation system and dural closure were used initially as well as being familiar with any problems that were experienced can save a lot of time.
Michael F. Continue in a large reverse question mark fashion. Course just superior to the pinna. Dura-Guard [Synovis Surgical Innovations. General Craniotomy Techniques Scalp Incision — Shave — Identify midline and contralateral frontal burr hole for ventricular catheter or intracranial pressure ICP monitor — Incorporate scalp lacerations if feasible — Start 1 cm anterior to the tragus at the root of the zygoma.
Mayfield head holder. Approaches Skin incision Craniotomy outline Dural incision stellate Fig. A burr hole and. Muscle Dissection — Incise temporalis fascia and muscle posteriorly. Midas Rex [Medtronic] with a B1 bit with a footplate is used to cut a large free bone flap that parallels the skin incision. Dural Opening — Dural opening is curved anteriorly in a gentle C in the frontal-temporal region starting from the initial burr hole — A posteromedial triradiate incision completes the exposure and provides access to the anterior..
Surgicel and Cottonoids — For a decompressive hemicraniectomy cultures are taken from the bone flap and the flap stored in sterile fashion double bagged in the bone bank. Evacuation of Hematoma — Subdural hematoma should be removed using gentle irrigation and suction and bipolar cautery.
It should allow access to the floor of the anterior and middle fossa and extend: Approaches Closure — — — — — — — — Dural closure with 4—0 Nurolon unless decompressive hemicraniectomy Surgicel over dura Epidural tack-up sutures: IV antibiotics for decompressive hemicraniectomy.
This allows muscle to be dissected off the brain when the bone flap is to be replaced usually 8 to 12 weeks later. ICP management. ICP monitor. DuraGen under pericranial or temporalis fascia flap to reduce scarring of flap to brain. This may imply that simple clipping may not be possible due to calcification of the neck. The aim is to approach aneurysm toward the neck and not the dome.
Inferior projection requires extra care in frontal retraction to avoid rupture. Superior projection requires the preparation of fenestrated clips because these aneurysms often project posteriorly and often have a broad neck.
Operating on patients with untreated hydrocephalus will increase the complication rate contusions. Giant aneurysms with a large amount of calcification or intra-aneurysmal thrombus may need or benefit from cardiac arrest to collapse wall and remove thrombus to facilitate clipping. In addition to what is discussed previously. Consider preparing for cerebral bypass.
May obviate need for digital subtraction angiography in operative planning in select cases large ICH requiring emergent evacuation or 3D reconstruction of particularly good quality. Confirm site of hemorrhage e.
Digital Subtraction Angiogram — Confirm evidence of aneurysm. As the aneurysm usually points away from the dominant side. This ensures venous drainage is not compromised. Relaxes the brain. Facilitates brain relaxation and prevents retraction injury. During temporary clipping. Prevents infection.
Allows for further brain relaxation to prevent retraction injuries. In poor grades and those with vasospasm. Prevents postoperative seizure. Prevents retraction injury and facilitates operative exposure.
Prevents ischemic complications. Positioning — Patient should be positioned supine. Helps prevent a rehemorrhage or hemorrhage. IV agents such as propofol should be used with limitation of inhalation agents. In poor grades. This is done by understanding the 3D anatomy and. Pia can then be bluntly dissected off the ipsilateral A1 and A2. This is similar to a standard pterional craniotomy except that the frontal exposure goes to the supraorbital notch. This allows for temporary clipping in case of premature rupture.
Vascular Lesions Surgery — Standard pterional skin incision with interfascial or subfascial technique to preserve frontalis branch of the facial nerve..
Telfa and place self retaining retractor on frontal lobe at junction of olfactory and optic nerves. The sphenoid wing is also drilled away until the superior orbital fissure is exposed. Always dissect away from the direction of the dome e. To prevent inadvertent occlusion with the aneurysm clip. This allows for less brain retraction because of a larger working space.
A small temporal retractor may also be placed. Bleeding must be controlled with Surgicel and not cautery to prevent an inadvertent perforator injury. After stripping the dura from the orbital roof and sphenoid wing. This will prevent rupture of the aneurysm during early dissection. Decide on the type of clip that is going to be required to achieve the goal of excluding the aneurysm from circulation while preserving patency in all other vessels. This allows for more working space.
Then remove temporary clips. Premature Rupture — Place large bore sucker as close as possible to bleeding site. Ruptured Base of Aneurysm — Control bleeding as described previously. Carefully inspect for clipping of normal vessels and proceed with Doppler and angiography.
Temporary clipping increases the risk of ischemia. Special Circumstances Temporary Clipping — This should only be used if the aneurysm is large and needs to be decompressed to allow for visualization of the A1s and A2s. This is particularly true in patients with two large A1s supplying the frontal lobes. For a large aneurysm. Always try and preserve the communicator. Vascular Lesions — If patient has bilateral A1s. This should only be done if absolutely necessary. In addition. It is most common in posteriorly and superiorly pointing aneurysms.
Obtain intraoperative angiography in all but the simplest aneurysms. MN] type — Aneurysm clips. Place the base of the triangle along the sylvian fissure abutting the partially resected sphenoid wing.
New Brunswick. Clear a space for the medial blade of a temporary clip. If the origin of the anterior choroidal artery is close to the neck. It may be possible to get a look at the communicator through this dissection window. Temporary proximal clipping under burst suppression may assist in softening the aneurysm.
The blades must be slightly longer than the neck by studying the tissue at the neck region. This often reduces the bleeding to a point at which definitive clipping can be accomplished in the setting of a tear in the neck.
An attempt should be made to place the distal clip proximal to the origin of the anterior choroidal to avoid any significant ischemic time to this vessels vascular territory. In cases where visualizing the blade at one side of the neck is more difficult that the other.
Rupture prior to bony portion of the craniotomy: Rupture after dural opening: Verify that the third nerve is free of the clip reconstruction. Vascular Lesions communicator. Inspect early after clip placement to reduce potential ischemic time.
Consider using the medial corridor opticocarotid triangle to visualize the clip pass and final closure. Deflate but do not dissect the sac off the third nerve as it is not necessary for complete recovery of the nerve. Apply papaverine if artery appears spastic from manipulation. Maximize visualization of this artery during clipping with permanent clip as higher closing pressures may damage artery.
Vascular Lesions — Just deflate the aneurysm after clipping. If you think it might be too tight. Dolenc Approach — We prefer the Dolenc approach of combined extradural and intradural clinoid removal — We perform both the extradural and intradural clinoid drilling under the microscope — The irrigating suction facilitates irrigation cooling during drilling under the microscope Exposure and Clipping of the Aneurysm — We use spinal drainage for clipping of ophthalmic artery aneurysms. Vascular Lesions Dolenc Approach see Chapter 7.
Pterional Approach — There is a potential for CSF leak if the ethmoid air cells are entered during drilling of the clinoid. In severe cases. Intraoperative Angiography — We always perform intraoperative angiography for clipping of ophthalmic artery aneurysms to confirm complete clip occlusion of the aneurysm.
For partially thrombosed giant aneurysms. We have liked this clip configuration because full view of the aneurysm for this type of aneurysm is not always possible. If extensive drilling has been used for low lying aneurysms. As the bone is drilled. Dural band may incorporate part of ophthalmic artery or aneurysm.
For aneurysms that are questionable whether intradural. The tendency with this type of reconstruction is to narrow the lumen of the carotid artery seen on intraoperative angiogram. Kevin Ju. For distal MCA aneurysms this will not be required.
Moderate hypotension can be used during the dissection of the aneurysm. Separately dissect skin. Small cortical veins within the sylvian fissure can be sacrificed without great concern if needed. We almost never use this approach.
MCA aneurysms typically occur at the bifurcation and may adhere to the temporal lobe. Procedure — Can remove slightly less bone from the lateral orbital roof and lesser wing of the sphenoid bone — Make 3 to 4 cm corticectomy in the superior temporal gyrus centered 2 cm posterior to the anteriormost aspect of the sylvian fissure — Use a subpial resection of the superior temporal gyrus to enter the horizontal portion of sylvian fissure to allow visualization of M2 segments of MCA — Dissect from distal to proximal within the sylvian fissure to identify the M1 segment.
Vascular Lesions Broad-based Aneurysms — Usually include either a portion of the M1 or M2 vessel wall in their necks — Common anatomic variations in this region necessitate complete dissection of the neck and fundus of the aneurysm and surrounding vessels Fusiform Aneurysms of the MCA Bifurcation — Often requires bypass procedures to reconstitute flow in the distal M2 segments.
Intraoperative — Once M1 and M2 segments are exposed. For most unruptured cases. Prior to beginning the microsurgical dissection. The clip blade will often end at 90 degrees with respect the M1 and parallel to the flow vector of the origin of the two M2 branches.
The caveat. This will clearly require imaginative modification for more complex lesions using fenestrated. A key difference is the location of the aneurysm. At the end of the procedure. One should learn from each case. Understanding the location of the aneurysm. Calcification of the aneurysm wall will also require special attention and care.
Such constructs can be used for most MCA aneurysms. More distal lesions will be closer to the surface. Proximal aneurysms require a more extensive bony resection at the skull base. This will allow better visualization and greater flexibility of paths to both approach and treat the aneurysm. Make a mental image of where you predict the aneurysm will be located.
It is critical in cases of ruptured MCA aneurysms to secure proximal control early in the dissection. For the treatment of unruptured aneurysms.
For the treatment of ruptured aneurysms. Understanding the relationship of the aneurysm to the sylvian fissure will allow you to treat the patient in a safer and more expeditious fashion.
Maxwell B. Far Lateral Approach. Vascular Lesions Special Equipment — Coarse diamond drill bit for removal of the occipital condyle. Orbitozygomatic Approach. Bleeding from the posterior-medial cavernous sinus is controlled with bone wax or Nu-knit Ethicon. M1 segment. Temporary clipping softens the aneurysm to facilitate its manipulation. Temporary Clipping — Temporary clipping should be considered when the aneurysm appears fragile or thin-walled.
PCOM artery may require sacrifice to widen the exposure. PCOM leads to the membrane of Liliequist. AChA leads to the choroidal fissure. The PCOM artery serves as the guiding landmark into thick clot. Vascular Lesions Fig. Perforators do not need to be freed along their entire length. Fenestrated clips are ideally suited for closing the distal neck. Dissection of these delicate perforators is minimized because of their susceptibility to spasm. A second nonfenestrated clip is then used to close the fenestration and complete the clip reconstruction.
Application of the temporary clip above the oculomotor nerve places the clip in the limited working space around the aneurysm and can crowd the field. Visualization is often improved after this initial tentative clipping. The site of residual filling is usually at the distal neck. Fenestrated clips are useful in completely shutting this particular spot on the neck.
Factors that complicate microsurgical clipping. These patients should be considered for endovascular coiling. These perforators must be anticipated and dissected painstakingly until free. In this endovascular era. In such a tight space with limited viewing room. Factors that complicate microsurgical clipping are: After clipping. Gives information about the morphology.
Vascular Lesions Approach — Infracallosal location: In proximal circulation aneurysms. Endovascular occlusion of the parent vessel may be performed. Postoperative — Adequate duration of antibiotics must be determined up to 6 weeks Complications — Meticulous dissection — CSF drainage for brain relaxation Management Pearls — Patients may have multiple lesions: Vascular Lesions — Immunocompromised patient primary immune disorder. Staphylococcus aureus.
Robert M. Cautery and interruption of feeding vessels contributing to the AVM require gentle use of well-maintained. This can sometimes be determined by the blood supply i. Lateral lenticulostriate feeders indicate internal capsule involvement and relative unresectability. AVM of medial posterior dorsal thalamus. AVM must present to accessible surface i.
Table Rhoton dissectors. Safe to resect if inferior to basal ganglia. Care to preserve peduncle perforators from AChA. Deep venous drainage taken last. Spinal Trauma Procedures G. Spinal Infection Procedures H. Other Spinal Procedures I. Spinal Fusion Instrumentation IV. Pediatric Procedures A. Pediatric Vascular Procedures B.
Pediatric Developmental Procedures C. Pediatric Spinal Procedures D. Pediatric Cranial Synostosis Procedures E. Pediatric Trauma Procedures G. Other Pediatric Procedures V. Endovascular Procedures VI. Radiosurgical Procedures VII. Minor Procedures Close Operative neurosurgery made concise, practical, and portable Operative neurosurgery made concise, practical, and portable Thieme congratulates Tanvir F.
The only portable handbook on operative techniques in neurosurgery, this step-by-step guide offers unparalleled coverage of every major operative procedure seen in daily practice. Concise chapters hold key clinical information on indications, preoperative planning, intraoperative technique, postoperative care, and complications, with insights and advice from renowned experts representing every main specialty in the field.
Features: Detailed coverage of all common neurosurgery procedures Over 40 new chapters featuring the latest information on intradural nerve sheath tumors, ulnar nerve submuscular transposition, lambdoid synostosis, radiosurgery for skull base lesions, and much more Succinct bullet-point format for quick and easy reference Management pearls at the end of every chapter highlight and expand on each procedure Nearly new drawings emphasize key surgical steps A reliable companion to Greenberg's Handbook, the second edition of Fundamentals of Operative Techniques in Neurosurgery is a must-have resource for those in training or for anyone who provides mentorship or support in the field of neurosurgery.