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 »  Abstract
 » Objective
 » Procedure
 » Outcome
 » Pearls and Pitfalls
 » Discussion
 » Conclusions
 » Objective
 » Procedure
 » Outcome
 » Pearls and Pitfalls
 » Discussion
 » Conclusions
 »  References

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NI SPECIAL FEATURE: OPERATIVE NUANCES: STEP BY STEP (VIDEO SECTION)
Year : 2020  |  Volume : 68  |  Issue : 4  |  Page : 800-802

Video Section-Operative Nuances: Step by Step – Single Stage Clipping of Ruptured Middle Cerebral Artery and Unruptured Basilar Top Aneurysm


1 Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jabalpur, Madhya Pradesh, India
2 Department of Neurosurgery, Super Speciality Hospital, New Delhi, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India

Date of Web Publication26-Aug-2020

Correspondence Address:
Dr. Sarat P Chandra
Department of Neurosurgery, Room 7, 6th Floor, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.293443

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 » Abstract 


Background and Introduction: Presence of multiple aneurysms, especially a combination of anterior and posterior circulation aneurysm in the same patient, is rare. Surgical clipping of both the aneurysms in the same sitting, although ideal, may be surgically challenging and requires a good preoperative planning.
Objective: In this video abstract, we present a case of a ruptured middle cerebral artery (MCA) aneurysm with a simultaneous occurrence of an unruptured basilar top aneurysm.
Surgical Technique: A 45-year-old female presented with modified Hunt and Hess grade II subarachnoid hemorrhage (SAH). CT scan showed diffuse SAH with a dense bleed in the left sylvian cistern and mild hydrocephalus. Angiography showed a left MCA aneurysm (34 mm size) with a bleb and also an un-ruptured basilar bifurcation/right posterior cerebral artery aneurysm (20 mm). The patient underwent a left frontotemporal craniotomy, zygomatic osteotomy, and clipping of both aneurysms. No temporary clips were applied. The extended craniotomy allowed the surgeon to reach to the base of the aneurysm.
Results: The patient had an uneventful recovery.
Conclusions: Simultaneous occurrence of both anterior and posterior circulation aneurysms are rare, but maybe tackled surgically with proper planning.


Keywords: Aneurysm, basilar bifurcation, clipping, middle cerebral artery, multiple aneurysms
Key Messages: Occurrence of basilar bifurcation and middle cerebral artery aneurysms require optimal planning to allow simultaneous clipping of both in the same sitting
Suggestion – Both anterior and posterior circulation aneurysm can be surgically clipped in the same sitting with optimal preoperative planning.


How to cite this article:
Chandra SP, Bajaj J, Ghonia R, Doddamani R. Video Section-Operative Nuances: Step by Step – Single Stage Clipping of Ruptured Middle Cerebral Artery and Unruptured Basilar Top Aneurysm. Neurol India 2020;68:800-2

How to cite this URL:
Chandra SP, Bajaj J, Ghonia R, Doddamani R. Video Section-Operative Nuances: Step by Step – Single Stage Clipping of Ruptured Middle Cerebral Artery and Unruptured Basilar Top Aneurysm. Neurol India [serial online] 2020 [cited 2020 Oct 20];68:800-2. Available from: https://www.neurologyindia.com/text.asp?2020/68/4/800/293443




Multiple cerebral aneurysms are challenging to treat. This is more so when there is simultaneous involvement of both anterior and posterior circulation systems.[1],[2],[3],[4] Multiple aneurysms may be managed by surgical clipping, endovascular intervention or even both, either in the same sitting or different sittings. However, it is preferable to perform surgery in the same sitting. The side of surgical approach in such cases is dictated by the side in which the middle cerebral artery (MCA) aneurysm is located. Anterior communicating artery (ACom) aneurysms may provide some flexibility.[1] We determine the side of the approach by the location of gyrus rectus bleed, the direction of the fundus, and type of circulation. The following article demonstrates the surgical technique of clipping of both MCA and basilar bifurcation aneurysms in the same sitting through the same surgical approach. We determine the surgical approach to BA by various factors such as the direction of the fundus, relationship to the posterior clinoid, size of the neck, and relationship to the perforators. Thus, the simultaneous clipping of both anterior and posterior circulation aneurysms require significant preoperative planning on a case to case basis


 » Objective Top


The video in this article demonstrates single-stage clipping of ruptured MCA and unruptured basilar bifurcation aneurysms using a frontotemporal craniotomy along with zygomatic osteotomy.


 » Procedure Top


The patient was operated under general anesthesia. For neuroprotection, the patient received propofol 1.5 mg/kg bolus followed by 100–200 μg/kg/min titrated to attain BSR (full form) of 75 + 5%. The propofol infusion was planned to be stopped when the temporary clip was to be removed.[5] The patient was provided with a central venous pressure line, an arterial line and two peripheral venous lines. Besides, intraoperative neuromonitoring was set up to use motor evoked and somatosensory evoked potentials to measure cortical reserve during temporary clipping. Neuronavigation was utilized (Stealth, Medtronics) which helped in planning craniotomy, guided approach to the aneurysm, and 3D orientation of the aneurysm along the location of adjacent perforators. The patient was positioned supine, head turned to one side, fixed on Mayfield clamp. A pillow was provided under the left shoulder to turn the patient partially to one side. A generous frontotemporal craniotomy was marked passing up to the zygomatic arch. A pedicled frontotemporal bone flap with zygomatic osteotomy was elevated. The orbital roof was flattened using a large diamond drill to allow maximum inferior visual access. The sphenoid ridge was drilled extensively. The dura was opened in a large semi-circular manner with the base over the sphenoid ridge. The sylvian fissure was opened widely. The MCA aneurysm was clipped first followed by basilar bifurcation aneurysm (see video and audio transcript). No temporary clipping was required, even though we preferred shrinking the unruptured BA aneurysm before clipping.

Video link: https://youtu.be/n7B_Nm6HPg4

Video timeline with audio transcript

0.12–0.35 min: A 45-year-old female with grade II subarachnoid hemorrhage on investigation showed a bleed in the left sylvian fissure. Angiography showed a left MCA aneurysm with evidence of rupture as suggested by presence of a bleb over fundus and an unruptured basilar bifurcation/right P1 aneurysm. 0.35–0.53 min: She underwent a left frontotemporal craniotomy and a zygomatic osteotomy. A single pedicle bone flap was elevated. The roof of the orbit was smoothened using a diamond drill. 1.02–1.10 min: It is important to drill the sphenoid ridge adequately. Following thorough irrigation, the dura is opened in a semi-circular manner. 1.10–1.39 min: To open the sylvian fissure is the next important step. I prefer to do this under high magnification using a fine hypodermic needle attached to a syringe. It is preferred that the fissure is opened from distal to proximal. As may be seen here, as the fissure is opened more widely, the MCA aneurysm comes into view after sucking off the blood. 1.39–2.02 min: The proximal part of the fissure is now being opened. The surgeon may use the suction as a retractor also to expose the aneurysm. As it may be seen here, I have not used any additional retractors, and the dome of the aneurysm is exposed both medially and laterally. 2.15–3.10 min: The MCA trunk now comes into view and the bifurcation along with the neck of the aneurysm may be seen clearly now. Following adequate exposure, I now place a curved clip over the neck of the aneurysm. As it can be seen here, we are not able to secure the bleb at the base of the aneurysm. It is important that this should be taken care of, otherwise there is a high risk of bleed from the same. The aneurysm is now rolled from side to side to ensure that the primary neck has been taken care of. 3.11–3.38 min: The sac of the aneurysm is now cut to ensure that there is no thrombus inside and the clip application is secure. Next, to secure the bleb, we attempt to place a curved clip, but as it may be seen here, the clip also compromises the parent artery. Hence, it is removed and a straight clip is applied over the bleb, which we feel should secure this adequately. 3.40–4.50 min: Dissection is now carried out posteriorly opening the cisterns and the arachnoid strands carefully. As it may be seen here, we prefer using micro-scissors and sharp dissection for the same, which is considered safest for such dissection. Trying to tear the dense arachnoid bands with a micro-dissector is not advisable and may even prove dangerous. The fine hypodermic needle is very useful to open carefully and dissect the perforators. These must be carefully preserved. Wide opening of all cisterns is advised, which includes chiasmatic cistern, carotico-optic cisterns and the entire length of sylvian cistern. 4.42–5.16 min: Following extensive and careful dissection and opening of the various arachnoid bands and cisterns, the Liliequist's membrane now come into view just behind the posterior clinoid process. A narrow blade retractor is placed to gently retract the carotid artery to further expose it. Once, this is opened, the posterior cerebral artery (PCA) comes into view. The basilar trunk, superior cerebellar artery and the PCA may now be seen clearly. 5.22–6.05 min: The narrow blade retractor is now gently retracted superiorly. The PCA is traced proximally and along its superior part, which now leads the surgeon directly to the aneurysm. Here, a fine “ball” dissector may be used to further expose the aneurysm. Using sharp dissection may result in inadvertent misadventures here. Hence it is not preferable. The perforators must be carefully dissected away from the dome of the aneurysm. Both the anterior and posterior surfaces of the aneurysm is defined. 6.07–6.38 min: Now, since this was an unruptured aneurysm, I preferred to use a bipolar under low setting and coagulate the surface of the aneurysm to shrink. This must be done carefully ensuring that the blades of the bipolar are held parallel to the surface of the aneurysm. Adequate irrigation must be provided to prevent the tearing of the aneurysm. Shrinking the aneurysm makes it easier for clip application and also prevents application of the temporary clip. 6.38–7.34 min: Now, we apply a straight standard permanent clip. Since the space is quite limited, I first apply the clip partly on the body of the aneurysm. Following this, I apply another straight clip over the neck of the aneurysm. This technique also prevented the proximal clip slipping over the aneurysm as the first clip prevented this. Following clipping, the opposite PCA and SCA are checked. At the end of surgery, I prefer to place a small piece of spongostan (gelfoam) soaked with undiluted papaverine to prevent perforator vasospasm. 7.34–7.41 min: Postoperative CT scan did not reveal any abnormality and showed clips in-situ.


 » Outcome Top


Following surgery, the patient had an uneventful outcome. Postoperative CT scan showed both clips. There was no further increase in the size of the ventricles or the development of any new onset infarct. A postoperative angiogram was not done as the patient did not prefer to undergo this procedure and we felt that intraoperative clip application was satisfactory.


 » Pearls and Pitfalls Top


The most crucial objective is to create an optimal approach to both the pathologies. Addition of a zygomatic osteotomy allows the surgeon to reach to more inferior access. If the basilar bifurcation is at a lower level, the inclusion of the orbit within the osteotomy would be necessary. If sometimes, the basilar bifurcation is high, then a simple pterional craniotomy may also suffice. The next important step would be to perform wide opening of all cisternal spaces to create enough access to the BA aneurysm. As shown in this video, wide opening of sylvian cistern, carotico-optic cistern, optic cisterns, and of course, Lilliquist's membrane is necessary.[4] Poor Hunt-Hess grade on admission, a long distance from aneurysm neck (from the posterior clinoid process), thrombosis, and large dome size are other adverse factors that should be considered before surgery.[1] Intraoperative rupture and injury to the perforators are the next most important things to consider. As shown in the video, we prefer to perform surgery under high magnification, which allows careful dissection of the perforators. Besides, we also prefer to use sharp dissection, either with an arachnoid knife, fine hypodermic needle, or a micro-scissors. Of course, it is essential to have adequate training to prevent inadvertent misadventures, e.g., injuring adjacent structures. The surgeon should always be prepared for temporary clipping of the main trunk, especially of the basilar trunk, in case he/she feels that clipping may not be done safely without this.

We prefer neuroprotection with propofol with BIS (Bispectral Index) monitoring. However, adenosine-induced asystole is the other option to be explored.[6],[7] Postoperatively, vasospasm is the most dreaded complication. We prefer to provide all patients with moderate hypertension (130–140/90–100 mm Hg) with hemodilution and hypervolemia.[8] It is essential to perform trans-cranial doppler at least once a day. Warning clinical features may include a sudden spike of fever or subtle obtundation of consciousness. We must make the diagnosis of vasospasm early, and follow it up with swift management. In our set up, this consists of an intra-thecal installation of papaverine, cervical sympathetic ganglionic block, and intra-arterial nimodipine.


 » Discussion Top


Currently, coiling/stenting is considered as the first option for treating BA aneurysm. Clipping is preferred when the configuration of the aneurysm is not suitable for coiling or because of the patient's poor financial status (especially to be considered for countries like India). The treatment is also significantly determined by the expertise of the center. Re-growth of a coiled BA can make a repeat surgery very challenging.[8] Other surgical approaches include sub-temporal, anterior temporal, and trans-cavernous[9],[10] approaches. The approach is decided by the experience and comfort of the surgeon. The endoscope also enhances the visualization of surgery, but the additional space occupied by an endoscope and the simultaneous handling of the scope requires expertise which may have a steep learning curve.


 » Conclusions Top


We have presented a video of surgical clipping of a ruptured MCA aneurysm and an unruptured basilar artery bifurcation aneurysm in the same setting. Frontotemporal craniotomy with zygomatic osteotomy and a traditional trans-sylvian approach was used. Adequate preoperative planning was critical in successful clipping of both aneurysms with a good functional outcome. We have discussed the operative nuances.

Declaration of patient consent

A full and detailed consent from the patient/guardian has been taken. The patient's identity has been adequately anonymized. If anything related to the patient's identity is shown, adequate consent has been taken from the patient/relative/guardian. The journal will not be responsible for any medico-legal issues arising out of issues related to the patient's identity or any other matters arising from the public display of the video.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Janjua MB, Reddy S, Welch WC, Ozturk AK, Price AV, Weprin B, et al. Concomitant ruptured anterior circulation and unruptured posterior circulation aneurysms: Treatment strategy and review of literature. J Clin Neurosci 2019;66:252-8.  Back to cited text no. 1
    
2.
Lan Q, Ma YY, Zhu Q. [Effects of supraorbital keyhole approach upon the clipping of distal basilar artery aneurysms]. Zhonghua Yi Xue Za Zhi 2013;93:672-5.  Back to cited text no. 2
    
3.
Neil-Dwyer G, Lang DA, Evans BT. The effect of orbitozygomatic access for ruptured basilar and related aneurysms on management outcome. Surg Neurol 1997;47:354-8; discussion 358-9.  Back to cited text no. 3
    
4.
Tjahjadi M, Kivelev J, Serrone JC, Maekawa H, Kerro O, Jahromi BR, et al. Factors determining surgical approaches to basilar bifurcation aneurysms and its surgical outcomes. Neurosurgery 2016;78:181-91.  Back to cited text no. 4
    
5.
Mahajan C, Chouhan RS, Rath GP, Dash HH, Suri A, Chandra PS, et al. Effect of intraoperative brain protection with propofol on postoperative cognition in patients undergoing temporary clipping during intracranial aneurysm surgery. Neurol India 2014;62:262-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Kumar VRR, Subramaniam SB, Murugan AB, Bapu KR. Endovascular pulmonary artery inflatable balloon-induced hypotension: A novel technique for clipping giant intracranial aneurysms. Neurol India 2017;65:566-9.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Britz GW. Adenosine-induced transient asystole. Methodist Debakey Cardiovasc J 2014;10:220-3.  Back to cited text no. 7
    
8.
Chandra SP, Kumar A. Clipping of a re-grown basilar bifurcation aneurysm following coiling: An extreme surgical challenge. Neurol India 2012;60:676-7.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Dolenc VV, Skrap M, Sustersic J, Skrbec M, Morina A. A transcavernous-transsellar approach to the basilar tip aneurysms. Br J Neurosurg 1987;1:251-9.  Back to cited text no. 9
    
10.
Nanda A, Vannemreddy PS, Vincent DA. Microsurgical and endoscopic approaches to the basilar bifurcation: Quantitative comparison of combined pterional/anterior temporal and orbitozygomatic extended approaches. Skull Base 2001;11:93-7.  Back to cited text no. 10
    




 

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