Orbitozygomatic Approach Clipping of an Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 18 (5) ◽  
pp. E160-E160
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Artery Aneurysm ◽  
Optic Chiasm ◽  
Anterior Communicating Artery ◽  
Aneurysm Neck ◽  
Institutional Review ◽  
Orbitozygomatic Approach ◽  
Interhemispheric Fissure ◽  
Aneurysm Occlusion ◽  
Neck Control

Abstract Anterior communicating artery (ACoA) aneurysms can orient rostrally into the interhemispheric fissure or caudally into the optic chiasm. The majority of these aneurysms project into the interhemispheric fissure. This patient had an ACoA aneurysm with a multilobulated appearance, and the primary lobe projected into the interhemispheric fissure. The cisterns were opened sharply via an orbitozygomatic approach to permit proximal, distal, and neck control. A permanent clip was applied across the aneurysm neck and on a small contralateral aneurysm. Postoperative imaging confirmed complete aneurysm occlusion. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Modified Orbitozygomatic Craniotomy for a Previously Coiled Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Artery Aneurysm ◽  
Mass Effect ◽  
Optic Chiasm ◽  
Anterior Communicating Artery ◽  
Aneurysm Neck ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Clip Occlusion

Abstract Clip occlusion of previously coiled aneurysms poses unique technical challenges. The coil mass can complicate aneurysm neck access and clip tine approximation. This patient had a previously ruptured anterior communicating artery (ACOM) aneurysm that had been treated with coil embolization. On follow-up evaluation, the patient was found to have a recurrence of the aneurysm, which prompted an orbitozygomatic craniotomy for clip occlusion. The approach provided a favorable view of the aneurysm neck with the coil mass protruding outside the aneurysm dome. Indocyanine green fluoroscopy was used to assist with ideal permanent clip placement along the aneurysm neck. The segment of coils present outside the aneurysm neck was removed to reduce mass effect on the optic chiasm. Postoperative imaging demonstrated aneurysm obliteration. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Intraoperative Rerupture and Surgical Clipping of a Small Superiorly Projecting Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (3) ◽  
pp. E288-E288
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Artery Aneurysm ◽  
Anterior Communicating Artery ◽  
Surgical Clipping ◽  
Institutional Review ◽  
Clip Application ◽  
Interhemispheric Fissure ◽  
Aneurysm Occlusion ◽  
Intraoperative Rupture ◽  
Temporary Clip

Abstract Anterior communicating artery (ACoA) aneurysms are prone to rupture even at smaller sizes. The surgical management of ACoA aneurysms is highly dependent on the spatial orientation of the saccular projection, categorized as inferior, superior, anterior, or posterior. Superior projecting aneurysms constitute approximately one-third of all aneurysms involving the ACoA. These aneurysms commonly project within the interhemispheric fissure; however, if the aneurysm is not high-riding, it can often be approached via a transsylvian trajectory. The patient presented after subarachnoid hemorrhage with a 3-mm superiorly projecting ACoA aneurysm. The lesion was approached via a right modified orbitozygomatic craniotomy with a transsylvian trajectory. The aneurysm reruptured after minimal manipulation of the dome. Mitigation of the intraoperative rupture was achieved through temporary clip application to bilateral A1 vessels. Bipolar coagulation and placement of 2 permanent clips facilitated final aneurysm occlusion. Postoperative imaging demonstrated patent bilateral A2 flow and no residual aneurysm filling. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Orbitozygomatic Craniotomy for Giant Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E5-E6
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Artery Aneurysm ◽  
Anterior Communicating Artery ◽  
Parent Artery ◽  
Aneurysm Neck ◽  
Anterior Communicating Artery Aneurysm ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Vessel Patency ◽  
Aneurysmal Neck

Abstract Giant intracranial aneurysms pose a significant surgical challenge because of the associated difficulty in achieving adequate visualization of the parent artery and aneurysm neck. This patient had an incidentally identified giant anterior communicating artery aneurysm. An orbitozygomatic craniotomy was performed for aneurysm exposure and aneurysmal neck dissection. Aneurysm dome opening and thrombectomy was performed to debulk the aneurysmal mass, which facilitated subsequent aneurysmal neck visualization. Sequential utilization of temporary clips of the bilateral A1 and bilateral A2 vessels reduced hemorrhage during thrombectomy. Multiple permanent clips were applied along the dissected aneurysm neck to permit occlusion. A small fracture of the aneurysm neck was identified, and cotton was applied with subsequent tamponade utilizing a fenestrated clip to maintain hemostasis. Indocyanine green fluoroscopy was used to verify parent and distant vessel patency. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Recurrent Giant Anterior Cerebral Artery (ACA) Aneurysm With Previous Coiling, Attempted Clipping Then Direct ACA-to-ACA Bypass: 2-Dimensional Operative Video

2020 ◽  
Vol 18 (4) ◽  
pp. E110-E110 ◽  
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Anterior Cerebral Artery ◽  
Surgical Intervention ◽  
Video Recording ◽  
Anterior Communicating Artery ◽  
Aneurysm Neck ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Icg Angiography ◽  
Aneurysmal Neck ◽  
Temporary Clip

Abstract Giant aneurysms are defined as lesions with a widest diameter of 2.5 cm or greater and account for 2% to 5% of all intracranial aneurysms. These lesions are challenging entities for microsurgical management with techniques such as direct aneurysmal neck clipping, aneurysm neck reconstructions, aneurysmotomy, and aneurysmectomy. This patient had a previously coiled, unruptured, superiorly projecting giant anterior communicating artery (ACom) aneurysm, eccentric toward the left, for which surgical intervention was undertaken. A left orbitozygomatic craniotomy was performed, and a temporary clip was applied to the bilateral proximal A1 segments. Aneurysmotomy was then performed with internal debulking of the aneurysmal thrombus. Aneurysmectomy and removal of the coil mass were performed. Next, the aneurysm neck was reconstructed using multiple surgical clips. After anticipated aneurysm neck reconstruction, indocyanine green (ICG) angiography demonstrated a lack of flow in the ipsilateral A2. The ACom was then transected along the aneurysm neck, and an end-to-end anastomosis of the distal A1 and proximal A2 was performed. Repeat ICG angiography demonstrated patency of the A1-A2 anastomosis. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Clipping of Complex Internal Cerebral Artery Terminus Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (3) ◽  
pp. E291-E291 ◽  
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Basal Forebrain ◽  
Video Recording ◽  
Aneurysm Neck ◽  
Microsurgical Clipping ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Orbitozygomatic Approach ◽  
Close Proximity ◽  
Perforator Vessels ◽  
Clip Occlusion

Abstract Internal carotid artery (ICA) bifurcation, or terminus, aneurysms are uncommon, and although they can be accessed with relative ease, clip occlusion of such aneurysms is often challenging due to the close proximity of basal forebrain perforator vessels. This patient had an incidentally discovered ICA terminus aneurysm and elected for microsurgical clipping. A modified orbitozygomatic approach was used to approach the aneurysm. The clipping was significantly complicated by the adherence and close proximity of the recurrent artery of Heubner to the aneurysm dome. Following successful dissection of the artery from the aneurysm dome and complete visualization of the aneurysm neck to avoid violation of perforator flow, successful clip occlusion of the aneurysm was achieved. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Surgical Clipping of an Unruptured Large Inferiorly Projecting Anterior Communicating Artery Aneurysm With Chiasmopathy: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (2) ◽  
pp. E144-E144
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Vision Loss ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Anterior Communicating Artery ◽  
Surgical Clipping ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
History Of ◽  
Maximal Angle ◽  
Brain Retraction

Abstract Anterior communicating artery (ACoA) aneurysms are a frequently encountered cerebrovascular entity that is associated with a high rupture rate at a smaller size and debilitating morbidity and mortality following rupture. The surgical management of ACoA aneurysms is highly dependent on the spatial orientation of the saccular projection, which is categorized as inferior, superior, anterior, or posterior. The inferiorly projecting aneurysms constitute a minority of all aneurysms involving the ACoA. The adherence of the aneurysm dome near the chiasm predisposes these patients to dome avulsion during frontal lobe retraction. This patient presented with a 1-mo history of progressive vision loss and was found to have a large inferiorly projecting ACoA saccular aneurysm measuring 2.04 cm × 1.54 cm with resultant chiasmopathy. The lesion was approached via a right modified orbitozygomatic craniotomy, which can provide a more favorable maximal angle of approach to the ACoA complex to avoid brain retraction. Intraoperative adenosine was administered to provide relaxation of the aneurysm dome to augment clip placement. Postoperatively, the patient's chiasmopathy demonstrated near-complete resolution. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Retrosigmoid Clip Anterior Inferior Cerebellar Artery Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 18 (4) ◽  
pp. E111-E111 ◽  
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Artery Aneurysm ◽  
Lateral Approach ◽  
Surgical Approaches ◽  
Anterior Inferior Cerebellar Artery ◽  
Parent Vessel ◽  
Aneurysm Neck ◽  
Institutional Review ◽  
Cerebellar Artery ◽  
Far Lateral Approach

Abstract Aneurysms of the anterior inferior cerebellar artery (AICA) are rare and require a considerate approach to facilitate successful and safe clipping. Surgical approaches vary and are dependent on the relation of the aneurysm to the internal acoustic meatus. An anterior approach should be considered for lesions medial to the meatus. Lesions adjacent to the meatus can be approached via a retrosigmoid or translabyrinthine approach. Lesions lateral to the meatus can be approached via a retrosigmoid or far lateral approach. This patient had a previously ruptured AICA aneurysm in the meatal region for which a retrosigmoid approach was selected. The approach involved locating the AICA distally and tracking it proximally to the origin off the basilar artery. A clip was applied across the aneurysm neck to facilitate occlusion while preserving parent vessel flow. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

scholarly journals Minimally Invasive Mini-orbitozygomatic Approach for Clipping an Anterior Communicating Artery Aneurysm: Virtual Reality Surgical Planning

2020 ◽  
Author(s):  
Nicolás González Romo ◽  
Franco Ravera Zunino
Keyword(s):  
Virtual Reality ◽  
Minimally Invasive ◽  
Surgical Planning ◽  
Artery Aneurysm ◽  
Patient Specific ◽  
Anterior Communicating Artery ◽  
Imaging Data ◽  
Advantages And Disadvantages ◽  
Orbitozygomatic Approach ◽  
Skull Base Anatomy

AbstractVirtual reality (VR) has increasingly been implemented in neurosurgical practice. A patient with an unruptured anterior communicating artery (AcoA) aneurysm was referred to our institution. Imaging data from computed tomography angiography (CTA) was used to create a patient specific 3D model of vascular and skull base anatomy, and then processed to a VR compatible environment. Minimally invasive approaches (mini-pterional, supraorbital and mini-orbitozygomatic) were simulated and assessed for adequate vascular exposure in VR. Using an eyebrow approach, a mini-orbitozygomatic approach was performed, with clip exclusion of the aneurysm from the circulation. The step-by-step process of VR planning is outlined, and the advantages and disadvantages for the neurosurgeon of this technology are reviewed.

scholarly journals Coaxial Access for Microcatheter Stabilization During Aneurysm Coiling: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Miri Kim ◽  
Rachyl Shanker ◽  
Anthony Kam ◽  
Matthew Reynolds ◽  
Joseph C Serrone
Keyword(s):  
Artery Aneurysm ◽  
Anterior Communicating Artery ◽  
Distal Catheter ◽  
Anterior Communicating Artery Aneurysm ◽  
Class 1 ◽  
Previously Treated ◽  
Aneurysm Occlusion ◽  
Intracranial Circulation ◽  
Aneurysm Coiling

Abstract Coaxial support is a fundamental technique utilized by neurointerventionalists to optimize distal catheter control within the intracranial circulation. Here we present a 41-yr-old woman with a previously coiled ruptured anterior communicating artery aneurysm with progressive recurrence harboring tortuous internal carotid anatomy to demonstrate the utility of coaxial support. Raymond-Roy classification of initial aneurysm coiling of class 1 resulted as class 3b over the 21 mo from initial treatment.1 The patient consented to stent-assisted coiling for retreatment of this aneurysm. Coaxial support was advanced as distally as possible in the proximal vasculature to improve catheter control, reducing dead space within which the microcatheter could move, decreasing angulations within proximal vasculature, limiting the movement of the native vessels, and providing a surface of lower friction than the endothelium. As the risk of recurrent subarachnoid hemorrhage in previously treated coiled aneurysms approaches 3%, retreatment occurs in 16.4% within 6 yr2 and in 17.4% of patients within 10 yr.3 Rerupture is slightly higher in patients who underwent coiling vs clipping, with the rerupture risk inversely proportional to the degree of aneurysm occlusion,4 further substantiating that coaxial support provides technical advantage in selected patients where additional microcatheter control is necessary for optimal occlusion. Pitfalls of this technique include vasospasm and vascular injury, which can be ameliorated by pretreatment of the circulation with vasodilators to prevent catheter-induced vasospasm. This case and model demonstration illustrates the technique of coaxial access in the stent-assisted coiling of a recurrent anterior communicating artery aneurysm and identification and management of catheter-induced vasospasm.

STENT REMODELING TECHNIQUE FOR COILING OF RUPTURED WIDE-NECK CEREBRAL ANEURYSMS: CASE REPORT

Neurosurgery ◽  
2009 ◽  
Vol 65 (5) ◽  
pp. E1007-E1008 ◽  
Author(s):  
Demetrius K. Lopes ◽  
Kalani Wells
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Artery Aneurysm ◽  
Anterior Communicating Artery ◽  
Parent Vessel ◽  
Aneurysm Neck ◽  
Acute Subarachnoid Hemorrhage ◽  
The Right ◽  
Wide Neck ◽  
Cordis Corporation

Abstract OBJECTIVE To describe a novel stent remodeling technique for the coiling of ruptured wide-neck cerebral aneurysms. CLINICAL PRESENTATION A 46-year-old man presented with acute subarachnoid hemorrhage (Hunt and Hess grade IV), intracerebral hemorrhage, and hydrocephalus. Cerebral angiography revealed a wide-neck small anterior communicating artery aneurysm. Conventional coiling was not successful because of coil instability and compromise of the dominant anterior cerebral artery. TECHNIQUE A 6-French shuttle sheath (Cook Medical, Indianapolis, IN) was advanced from a right femoral approach into the right common carotid artery. To protect the parent vessel during coiling without compromising blood flow, a Prowler Select Plus catheter (Cordis Corporation, Bridgewater, NJ) was navigated across the aneurysm neck. Subsequently, an Enterprise stent (22-mm length; Cordis Corporation) was partially deployed across the aneurysm's wide neck. It was very important to watch the distal markers of the stent and lock the stent delivery wire to the Prowler Select Plus with a hemostatic valve once the stent was halfway deployed. This maneuver was essential to prevent further deployment of the stent. The SL-10 microcatheter and Synchro 14 wire (Boston Scientific, Natick, MA) were carefully navigated to the aneurysm passing through the partially deployed stent. Coils were then delivered to the aneurysm using the stent as a scaffold. After coiling, the SL-10 microcatheter was removed and the stent was recaptured into the Prowler Select Plus catheter. During the recapture, there was initial resistance. This was easily overcome after deploying the stent a little more before resheathing. During the procedure, the patient received 2000 U of heparin after the first coil was detached in the aneurysm. CONCLUSION The stent remodeling technique is a novel endovascular technique that can be used to treat ruptured wide-neck aneurysms and maintain patency of parent vessels, avoiding the use of antiplatelet therapy in acute subarachnoid hemorrhage.

Sign in / Sign up

Export Citation Format

Share Document