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 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.

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 Transpetrous Clip Occlusion of a Giant Midbasilar Aneurysm Using Hypothermic Cardiac Arrest: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (2) ◽  
pp. E143-E143
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Cardiac Arrest ◽  
Surgical Intervention ◽  
Video Recording ◽  
Mass Effect ◽  
Institutional Review Board ◽  
High Morbidity ◽  
Vestibulocochlear Nerve ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Clip Occlusion

Abstract Basilar trunk aneurysms are historically associated with extremely high morbidity. The complexity of circumflex perforator arteries responsible for the perfusion of the brainstem makes surgical intervention for these lesions particularly challenging. This patient had a giant midbasilar aneurysm that encompassed multiple perforators but was associated with progressive mass effect and debilitating morbidity. Therefore, a transpetrous approach was used with transposition of the facial nerve and sacrifice of the vestibulocochlear nerve to permit access to the aneurysm. Hypothermic cardiac arrest was used to permit dome manipulation with a tandem fenestrated clipping of the aneurysm. Postoperative imaging demonstrated a reduction in mass effect attributable to the significantly reduced dome size and persistence of flow via a reconstructed basilar trunk. 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 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.

Dual Microwire Rail Technique to Advance a Microcatheter Past the Ostium of a Dissecting Carotid Artery Aneurysm for Flow Diverter Deployment: 2-Dimensional Operative Video

2019 ◽  
Author(s):  
Kunal Vakharia ◽  
Stephan A Munich ◽  
Muhammad Waqas ◽  
Matthew J McPheeters ◽  
Elad I Levy
Keyword(s):  
Carotid Artery ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Carotid Artery Aneurysm ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Wall Apposition ◽  
Flow Diverters

Abstract Flow diversion using a Pipeline embolization device (PED; Medtronic, Dublin, Ireland) is an effective therapy for treating cavernous aneurysms. Currently, flow diverters require a 0.027-inch microcatheter for deployment. To navigate across these aneurysms, a 0.014-inch microwire is used, which often does not offer a sturdy enough rail to advance a 0.027-inch microcatheter past dissecting artery aneurysm ostia. We present a patient with a right cavernous dissecting carotid artery aneurysm. A step off between the 0.027-inch VIA microcatheter (MicroVention Terumo, Tustin, California) and 0.014-inch Synchro 2 microwire (Stryker Neurovascular, Fremont, California) resulted in difficulty with navigation of the microcatheter across the dissected portion of the aneurysm. A dual microwire rail technique involving two 0.014-inch Synchro 2 microwires was used to advance the VIA microcatheter past the dissecting artery aneurysm ostia for PED deployment. The introduction of the second microwire eliminated the step off between the microwire and microcatheter, providing a stronger rail and easier navigation of the microcatheter, without aggressive pushing. Postembolization runs showed optimal wall apposition and contrast stasis within the aneurysm, with successful flow diversion of the aneurysm. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary.

scholarly journals Optic Nerve Decompression from Coil Mass Impingement and Adhesion Following Large Internal Cerebral Artery Aneurysm Coil Embolization: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E389-E390
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Optic Nerve ◽  
Obstructive Hydrocephalus ◽  
Video Recording ◽  
Artery Aneurysm ◽  
Mass Effect ◽  
Preoperative Imaging ◽  
Cranial Neuropathy ◽  
Microsurgical Decompression ◽  
Institutional Review ◽  
Cerebral Artery Aneurysm

Abstract Aneurysmal mass effect is a consideration for treatment modality selection, particularly in the setting of cranial neuropathy or obstructive hydrocephalus. However, the extent of consequences related to mass effect is not always apparent periprocedurally from the original treatment. This unique video highlights a patient who underwent previous coil occlusion of a supraclinoid internal carotid artery (ICA) aneurysm with subsequent occlusion of the ipsilateral ICA who presented 16 yr later with progressive worsening hemianopsia. The preoperative imaging was suggestive of coil mass impingement prompting operative intervention for decompression. Intraoperative inspection demonstrated that the coil mass was exerting mass effect on the optic nerve and had partially migrated out of the aneurysm dome into the optic nerve. The ICA was also transected and mobilized to further reduce mass effect. Careful microsurgical decompression was achieved and prevented further visual compromise. 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 Left Interhemispheric Craniotomy for Resection of Cavernous Malformation: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (4) ◽  
pp. E154-E154
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Lateral Ventricle ◽  
Cavernous Malformation ◽  
Third Ventricle ◽  
Video Recording ◽  
Mass Effect ◽  
Cavernous Malformations ◽  
Transcallosal Approach ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Surgical Field

Abstract Thalamic cavernous malformations pose variable surgical challenges given that the location and size of the lesion often determine the approach surgical trajectory. The patient in this case has a large thalamic cavernous malformation that results in a mass effect on the third ventricle and directly abuts the lateral ventricle. A small interhemispheric craniotomy is performed to allow for an anterior interhemispheric transcallosal approach to the lesion. The lateral ventricle is accessed, and the septum is removed to enhance visualization of the surgical field. A small rim of normal parenchyma on the lateral margin of the thalamus is transgressed, and the cavernous malformation is entered. The lesion is removed in a piecemeal manner. Use of counter traction assists with the piecemeal removal. The lighted suction is critical during inspection and manipulation of the lesion within the resection cavity given the limited lighting deep within the cavity. The lesion was removed completely, and postoperative imaging confirms gross total resection. The patient gave informed consent for surgery and video recording. The institutional review board approval was deemed unnecessary. Used with permission from the Barrow Neurological Institute.

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