scholarly journals Left Modified Orbitozygomatic Approach for Clipping of Multilobulated Middle Cerebral Artery Bifurcation Aneurysm: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E386-E386 ◽  
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Video Recording ◽  
Parent Vessel ◽  
Microsurgical Treatment ◽  
Institutional Review ◽  
Bifurcation Aneurysm ◽  
Orbitozygomatic Approach ◽  
Clip Application ◽  
Clip Occlusion

Abstract Middle cerebral artery (MCA) aneurysms are associated with one of the most favorable approaches for microsurgical treatment; however, aneurysm geometrics can pose challenges during clip application. The surgeon must be mindful of the clip configuration options available during the planning of ideal clip occlusion for irregular or multilobulated aneurysm domes. This patient had an incidental multilobulated MCA bifurcation aneurysm and underwent an orbitozygomatic approach for microsurgical treatment. Proximal and distal control of the aneurysm were achieved, and complete clip occlusion was achieved following the placement of a single permanent clip. Flow within the parent vessel was well preserved, and complete aneurysm occlusion 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 Orbitozygomatic Craniotomy for Clipping a Complex Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (2) ◽  
pp. E33-E33
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Sylvian Fissure ◽  
Parent Artery ◽  
Parent Vessel ◽  
Institutional Review ◽  
Vessel Patency ◽  
Mca Aneurysm

Abstract Middle cerebral artery (MCA) aneurysms pose a surgical challenge because of the large caliber of the parent artery and the common need to dissect the sylvian fissure to permit access to the proximal and distal control. The neck of the aneurysm should be generously dissected to permit visualization of any adjacent lenticulostriate perforators. This patient demonstrated a left-sided wide-necked bilobed MCA aneurysm at the M1 bifurcation. The aneurysm was approached using a left orbitozygomatic craniotomy with distal sylvian fissure dissection. A single curved clip was applied for aneurysm occlusion, and postoperative angiography demonstrated aneurysm obliteration with parent 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 Excision of a Large Complex Left Middle Cerebral Artery Aneurysm With a Middle Cerebral Artery—Middle Cerebral Artery and Superficial Temporal Artery—Middle Cerebral Artery Bypass: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (2) ◽  
pp. E147-E148
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Bypass ◽  
Superficial Temporal Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Temporal Artery ◽  
Left Middle Cerebral Artery ◽  
Bifurcation Aneurysm ◽  
Orbitozygomatic Approach

Abstract Revascularization techniques for microsurgical manage-ment of middle cerebral artery (MCA) bifurcation aneurysms are often necessary for treatment of fusiform or giant aneurysms. Augmentation of the standard pterional approach to include an extended orbitozygomatic or modified orbitozygomatic approach provides a wider and more favorable approach to the MCA when attempting revascularization. Direct excision of a giant aneurysm (aneurysmectomy) with mobilization and reanastomosis of the MCA afterward has been reported. This patient had a giant MCA bifurcation aneurysm for which aneurysmectomy and distal reanastomosis were performed between the M1 and two M2 branches via a modified orbitozygomatic craniotomy. A second bypass between a third M2 branch at the ipsilateral superficial temporal artery was performed. Postoperative angiography confirmed patency of the bypasses. 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.

Pterional Craniotomy for Anterior Temporal Artery to Middle Cerebral Artery Bypass: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (1) ◽  
pp. E43-E43
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Bypass ◽  
Video Recording ◽  
Temporal Artery ◽  
Institutional Review ◽  
Bifurcation Aneurysm ◽  
Aneurysm Occlusion ◽  
Complete Thrombosis ◽  
Distal Perfusion

Abstract Broad-based aneurysms of the middle cerebral artery M1 bifurcation usually involve aneurysmal inclusion of an M2 vessel wall within the neck. This necessitates a consideration of performing a bypass to preserve the patency of distal perfusion. The patient in this video is a 17-yr-old man who presented after experiencing a small stroke and was found to have a partially thrombosed giant middle cerebral artery M1 bifurcation aneurysm with an M2 branch arising from the aneurysm. To maintain the perfusion of the M2 brain, the anterior temporal artery was used to perform a side-to-side anastomosis with the M2 brain at risk. A distal clip was determined to be not necessary for aneurysm occlusion because the aneurysm was almost completely thrombosed before the operation and the bypass flow was anticipated to be sufficient to facilitate complete thrombosis. 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 Challenges Associated With Anterior Choroidal Artery Aneurysm Clipping: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (3) ◽  
pp. E289-E289
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Region Of Interest ◽  
Artery Aneurysm ◽  
Anterior Choroidal Artery ◽  
Parent Vessel ◽  
Institutional Review ◽  
Adjacent Structures ◽  
Clip Application ◽  
Anterior Choroidal ◽  
Choroidal Artery

Abstract Surgical treatment of anterior choroidal artery (AChA) aneurysms is challenging because of the constrained operative corridor and limitations imparted by the surrounding rigid structures during the exposure. The AChA most commonly arises as a single branch from the communicating (C7) segment of the internal carotid artery but has 2 to 4 branches in approximately one-third of cases, and aneurysms generally arise from the parent vessel interface with these branches. This patient experienced a sentinel headache 4 d before presenting with subarachnoid hemorrhage. The patient had a large right AChA aneurysm with a unique configuration in which the parent vessel was located anterior to the aneurysm. Endovascular therapy was aborted because there was an AChA branch at the base of the aneurysm. An orbitozygomatic craniotomy was performed that provided transsylvian access to the region of interest. Clip application was challenging because of the close proximity of the branch vessels. Intraoperative indocyanine green evaluation and postoperative angiogram showed patency of the AChA and posterior communicating artery. This video demonstrates the surgical challenge associated with AChA aneurysms because of the proximity of adjacent structures and highlights the importance of meticulous technique during clip application. 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 Previously Coiled Giant Basilar Apex Aneurysm: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (5) ◽  
pp. E199-E199
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Video Recording ◽  
Institutional Review Board ◽  
Anterior Circulation ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Orbitozygomatic Approach ◽  
Clip Application ◽  
Complicating Factors ◽  
The Right ◽  
Significant Size

Abstract Basilar apex aneurysms are generally preferentially managed with endovascular intervention; however, these lesions can demonstrate refractory persistence despite this treatment and, in such cases, must be managed microsurgically. Successful navigation to and manipulation of the basilar apex through the orbitozygomatic approach requires an intricate understanding of the cerebrovascular microanatomy and arachnoid planes within interpeduncular fossa and comfort with use of the operating microscope for the long surgical trajectory to the basilar apex. This patient had a multiply recurrent basilar apex aneurysm; 3 previous coil embolization attempts had been made without successful aneurysm obliteration. This case presented multiple complicating factors, including the presence of a large coil mass and the significant size of the basilar apex lesion. An Allcock test was performed to determine the collateralization across the posterior communicating arteries, and no posterior communicating arteries were visualized, which suggested isolation of the posterior and anterior circulation. A fenestrated clip was utilized from the right side to occlude the base of the aneurysm. Single-clip application was not impeded by the coil mass. Postoperative angiography demonstrated complete occlusion of the aneurysm. 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 Moyamoya Disease Superficial Temporal Artery-to-Middle Cerebral Artery Onlay: 2-Dimensional Operative Video

2020 ◽  
Vol 18 (6) ◽  
pp. E229-E229
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Video Recording ◽  
Temporal Artery ◽  
Low Flow ◽  
Institutional Review ◽  
Direct Anastomosis

Abstract The most frequently performed low-flow bypass procedure is the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. If available, a suitable M2 or M3 cortical branch is anastomosed to the donor vessel. This patient had severe moyamoya disease with an ipsilateral perfusion deficit and transient ischemic attacks. Given the need for revascularization, an STA-to-MCA bypass was performed. There was no suitable recipient M3 branch for direct anastomosis, and therefore an indirect bypass was performed by onlaying the STA onto the cortical surface and suturing the adventitia of the STA to the arachnoid of the underlying cortex. The dural leaflets were then inverted to potentiate further revascularization of the underlying cortex. The patient remained at their neurological baseline and demonstrated an enhanced perfusion of the ipsilateral MCA territory on follow-up evaluation. 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 Bonnet Bypass for Left Superficial Temporal Artery Bifurcation to Right Middle Cerebral Artery: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (5) ◽  
pp. E201-E202 ◽  
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Saphenous Vein ◽  
Superficial Temporal Artery ◽  
Video Recording ◽  
Temporal Artery ◽  
Interposition Graft ◽  
Institutional Review ◽  
Bypass Patency ◽  
Pass Through

Abstract A bonnet bypass is a long interposition graft bypass used for extracranial to intracranial revascularization, which is useful in patients who do not have a suitable ipsilateral donor or in whom the ipsilateral donor must be sacrificed. This interposition graft is commonly the radial artery or saphenous vein. The only practical difference in this technique for revascularization is that an interposition graft must pass through the subgaleal space to the contralateral scalp to allow for reimplantation at the desired contralateral point of anastomosis. This patient underwent a bonnet bypass for revascularization of the middle cerebral artery (MCA) perfusion territory utilizing the contralateral superficial temporal artery (STA). A saphenous vein was used as the interposition graft, which was anastomosed to an M2 segment bifurcation. The graft was then temporarily occluded and passed within a calvarial trough to the contralateral frontoparietal region. The graft was then anastomosed to the contralateral STA at a bifurcation to accommodate the graft size mismatch. The patient tolerated the bypass procedure well and demonstrated bypass patency on postoperative angiographic imaging. 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 Basilar and Middle Cerebral Artery Aneurysms: 2-dimensional operative video

2020 ◽  
Vol 19 (3) ◽  
pp. E290-E290
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Preoperative Planning ◽  
Video Recording ◽  
Surgical Clipping ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Complete Obliteration ◽  
Mca Aneurysm ◽  
Middle Cerebral Artery Aneurysms

Abstract Careful preoperative planning for patients with multiple intracranial aneurysms is paramount given the importance of an appropriate trajectory and exposure for each aneurysm that will be clipped. The general principle is to clip aneurysms in a retrograde manner, such that more distal aneurysms are clipped earlier, and more superficial aneurysms are clipped later. This patient had unruptured middle cerebral artery (MCA) and basilar artery (BA) apex aneurysms and elected for surgical clipping of both lesions. An orbitozygomatic craniotomy ipsilateral to the MCA aneurysm was performed to permit clipping of both lesions. The dissection initially focused on exposure of the MCA aneurysm and then focused on the carotid-oculomotor triangle to permit basilar apex exposure and aneurysm clipping. The MCA aneurysm was clipped second. Postoperative imaging demonstrated complete obliteration of both aneurysms. 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.

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