Name: minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms
Uploaded: 2015-08-11T13:00:00.000+00:00
Duration: 11 min 58 s
Description: Watch this Scientific Journal Video about Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms at JoVE.com

The authors have no acknowledgments.

NOTA: Prima di eseguire questa procedura, ottenere tutte approvazione istituzionale necessario e il consenso del paziente. 1. Tecnica chirurgica <ol><li> Indurre paziente con anestesia generale. </li><li> Posizionare linea arteriosa radiale per il monitoraggio della pressione arteriosa. </li><li> Posizionare il paziente in posizione supina sul tavolo operatorio. </li><li> Dopo che la testa è bloccato nel supporto Mayfield Testa utilizzando tecniche standard per una craniotomia pterional, posizionare la testa di 30 ° -45 ° con il lato omolaterale verso il soffitto, tranne-comunicante anteriore aneurismi in cui la testa è posto a 60 ° per consentire una migliore visualizzazione attraverso la fessura interemisferica. </li><li> Posizionare la linea mediana del collo e tradurre anteriormente per massimizzare il drenaggio venoso giugulare per prevenire l&#39;edema cerebrale e quindi estendere la testa per posizionare zigomo omolaterale al più alto punto-questo permette di relax lobo frontale e elevation dal tetto orbitale durante la dissezione senza l&#39;uso di divaricatori. </li><li> Agganciare i capelli, in preparazione per lo standard incisione cuoio pterional; utilizzare circa uno a striscia di due pollici dietro l&#39;attaccatura dei capelli. </li><li> Sterilmente preparare la pelle e drappeggio l&#39;area chirurgica secondo standard di cura. </li><li> Eseguire un cuoio capelluto incisione curva standard per un approccio pterional estende dalla linea mediana del cuoio capelluto dietro la linea sottile con una curva dolce posteriormente ed inferiormente verso la trago porvi fine circa 3 mm anteriormente al trago e al livello del bordo superiore dello zigomo . Eseguire questa incisione fino al cranio sopra la linea temporale superiore e alla fascia muscolare a livello del muscolo temporale. </li><li> Utilizzare elettrobisturi per cute emostasi con il dispositivo bipolare. </li><li> Tagliare il muscolo temporale fino al cranio con il dispositivo di elettrocauterizzazione monopolare Bovie. </li><li> Sollevare un lembo miocutaneo mantenendo il muscolo temporale attaccato alinferiore del cuoio capelluto per ora. Ami sono utilizzati per rovesciare il lembo dopo il muscolo temporale è elevata dal cranio con una combinazione di elettrocauterizzazione monopolare e un scollaperiostio. </li><li> Eseguire una dissezione sottofasciale inversa nel piano avascolare dalla superficie inferiore del lembo miocutaneo con le forbici Metzenbaum, mantenendo la fascia e cuscinetto adiposo subfacsial con il cuoio capelluto per evitare lesioni al nervo facciale. </li><li> Fissare il muscolo temporale posteriormente ed inferiormente per esporre la regione pterional con &quot;stella&quot; ami. </li><li> Tenere tutti i componenti del lembo miocutaneo umido con una garza bagnata. </li><li> Praticare un singolo temporale 5 millimetri bava fori nel lato posteriore-maggior parte del craniotomia pianificata con da 2 mm taglio bava in modo che la piastra di fondo del trapano laterale di taglio può essere inserita in questo foro e quindi utilizzare un trapano side-Taglio con una pedana per rimuovere il pollice dimensioni (circa 3 x 4 cm) a forma di rene craniotomia centecolore rosso anteriormente intorno al pterion. </li><li> Utilizzando un No. 1 Penfield, separare la dura su tutti i lati del pterion e hanno un assistente ritrarre delicatamente la dura dalla superficie dell&#39;osso che viene forato per minimizzare il rischio di penetrazione della dura e causando lesioni corticale. </li><li> Rimuovere il pterion con un trapano: anteriormente, fino a quando gli aspetti superiori e laterali del tetto orbitali sono lisci e appiattiti verso il basso per la tabella esterna corticale dell&#39;osso, senza entrare nell&#39;orbita, per massimizzare l&#39;esposizione subfrontale; medialmente, trapano fino a quando la fessura orbitale superiore dura è esposto e rimuovere eventuali piccoli pezzi di osso che potrebbero interferire con l&#39;esposizione mediale utilizzando una punta da trapano o un dispositivo di taglio portatile Lempert osso. Assicurarsi che eccellente emostasi di tutte le superfici dei tessuti molli e delle ossa sono state ottenute al fine di evitare il sangue che cola nello spazio intradurale durante la dissezione del cervello e l&#39;esposizione aneurisma, utilizzando electrocaurtery e cera osso, se necessario, prima di aprire la dura. </li><li>Elevare delicatamente la dura e utilizzare un bisturi No. 11 per penetrare la dura e quindi utilizzare le forbici durale per creare un&#39;apertura &quot;a C&quot; nella dura con la base al pterion. Fissare il piano dura contro l&#39;osso corticale esterna dell&#39;orbita senza dover volantini ridondante durale che sarebbero visualizzazione altrimenti oscuro prossimale Sylvian Abisso e regione subfrontale. Ciò può essere eseguito utilizzando 4-0 Surgilons suture a virare la dura al cuoio capelluto. </li></ol> 2. Cervello Relax <ol><li> Dare 25-50 g di mannitolo al momento della rimozione lembo osseo per rilassare il cervello, se anestesia concorda sul fatto che la pressione del sangue tollererà diuresi. NOTA: Questo permetterà di tempo per la diuresi a verificarsi e in ultima analisi, sarà rilassare il cervello per aiutare a massimizzare la gravità dipende retrazione del cervello durante la dissezione. </li><li> Tenere fine espirazione pCO2 tra 30-35 mm Hg per raggiungere lieve ipercapnia. NOTA: Questo permetterà in modo sicuro per il relax e il cervello maximize gravità dipendente retrazione del cervello durante la dissezione. </li><li> Evacuare liquido cerebrospinale (CSF) per favorire il rilassamento del cervello aprendo le cisterne aracnoide nel interoptic, carotide ottica, e cisterne carotide-oculomotorie e pazientemente CSF aspirazione fino al raggiungimento del rilassamento del cervello desiderato. NOTA: Questo richiede in genere circa 1 min; senza scarico lombare è necessaria con questa tecnica e si apre drammaticamente corridoi chirurgiche. </li></ol> 3. Sylvian Fissure Dissection <ol><li> Portare il microscopio intraoperatorio con il boccaglio nel campo usando tecniche sterili. Anche portare sedie chirurgici con supporto braccio nel campo sterilmente per massimizzare destrezza bimanuale e per prevenire il braccio chirurgo e l&#39;affaticamento della mano. NOTA: Il boccaglio deve essere regolata prima drappeggio in modo che il chirurgo può spostare il microscopio con la bocca contemporaneamente guardando attraverso i pezzi oculari. </li><li> Eseguire dissezione. NOTA: percomunicante anteriore aneurismi dell&#39;arteria, senza dissezione Sylvian Abisso è necessario e il minimo (2-3 mm solo in casi estremi, ma questo è un evento raro) o nessuna resezione giro retto è necessaria utilizzando dissezione solo subfrontale; tutte le altre località circolo anteriore aneurisma sopraclinoidea (compresi comunicante posteriore) richiedono &lt;1 cm prossimalmente Sylivan Abisso dissezione per esporre il sopraclinoidea arteria carotide interna, i suoi rami (comunicante posteriore e anteriore arterie della coroide), l&#39;interno capolinea carotide, la A1 e M1 origini e prossimali A2 e segmenti M2 distali ai rispettivi biforcazioni. Complessivamente, l&#39;esposizione Sylvian Abisso era dime-size (1 cm x 1 cm) e nessun divaricatori cerebrali sono stati utilizzati per uno dei casi segnalati. Gravity dipendente relax cervello era sufficiente per ottima esposizione delle strutture dei tessuti molli e vasi necessarie per eseguire la clip legatura chirurgica nei settori di cui sopra. </li><li> Utilizzando manipula bimanualzione con microstrumenti chirurgici aprire delicatamente i corridoi aracnoide, tenendo il tessuto cerebrale da parte con il bordo del dispositivo maniglie strumento o di aspirazione, se necessario attraverso questa esposizione. NOTA: la preferenza dell&#39;autore anziano è quello di utilizzare una punta di aspirazione 4-Francese Fukishima nella mano non dominante e nella mano baionette bipolari dominanti per scollamento o microscissors per la dissezione tagliente. Strisce inumidito Telfa sono collocati sulla superficie del cervello nel sito di manipolazione per evitare lesioni corticale. Cottonoids spesso attaccano alla superficie del cervello e non possono essere facilmente avanzati profondo come la dissezione progredisce, senza causare lievi lesioni corticale. </li><li> Utilizzare il boccaglio sul microscopio operatorio frequente per regolare la portata e concentrarsi lunghezza come necessario allontanare le mani nel settore. </li><li> Fissare l&#39;aneurisma in modo standard, utilizzando l&#39;aspirazione più spesso in mano non dominante per mantenere il corridoio chirurgica e la visualizzazione gratuita di CSF. </li><li> Dopo la clip di collocamento, effettuare Doppler intraoperatoria della cupola dell&#39;aneurisma di confermare la cessazione del flusso, così come i vasi di afflusso e deflusso per confermare il flusso ed esaminare con attenzione i vasi del collo dell&#39;aneurisma e genitori. Ci riserviamo intra-operatoria angiografia digitale (DSA) per comunicante anteriore aneurismi e quelle aneurismi tagliate dove afflusso, deflusso, o al collo dell&#39;aneurisma non possono essere visualizzati in tutto o c&#39;è un problema con Doppler intra-operatoria. DSA intra-operatoria è preferito su verde indocianina (ICG) angiografia perché quando più clip da aneurisma sono utilizzate per ricostruire il collo dell&#39;aneurisma, la clip può ostacolare la visualizzazione. NOTA: Una volta che l&#39;aneurisma è stato tagliato in modo sicuro, il microscopio è rimossa dal campo e il cervello irrigato con soluzione fisiologica per minimizzare la quantità di pneumocefalo dopo la chiusura. </li><li> Dopo aver ispezionato la clip per aneurisma occlusione con il Doppler, la cupola aneurisma è il motto di spirito perforata<html> ha 22 ago G attaccato al tubo per via endovenosa e una siringa da 10 ml e aspirazione manualmente aspirato per confermare aneurisma occlusione. </li><li> Reapproximate la dura nativa con 4-0 surgilon e coprire con un sostituto sintetico durale se una chiusura stagna non è in grado di ottenere correttamente. </li><li> Placche ossee sicuri con un sistema di metallizzazione per standard di cura. </li><li> Fissare il bordo frontale del filo lembo osseo contro l&#39;osso nativo per evitare spazio tra i due che non sarebbe esteticamente gradevole dopo i tessuti guariscono. </li><li> Reapproximate la fascia muscolo temporale con interrotti 2-0 punti di sutura Vicryl. Fissare la parte superiore del muscolo temporale con un Vicryl punto 2-0 alla piastra metallica frontale per reapproximate alla linea temporale superiore. </li><li> Reapproximate la galea con 3-0 punti di sutura Vicryl e chiudere il cuoio capelluto in modo standard utilizzando graffette, nylon o prolene. Condite con bende sterili per preferenza del chirurgo. </li></ol>_title &quot;&gt; 4. Post-trattamento di cura <ol><li> Ammettere paziente al reparto di terapia intensiva dopo il trattamento e mobilitare con il personale infermieristico, non appena la sedazione o anestesia generale ha portato fuori abbastanza per farlo, in genere entro 6 ore di estubazione. </li><li> Ordine di terapia fisica e occupazionale per iniziare post-operatorio primo giorno, al fine di valutare il paziente per lo scarico sicuro da casa, se ci fossero dubbi da parte del personale infermieristico. </li><li> Scaricare il paziente quando sono soddisfatti i criteri: dolore controllato solo con farmaci per via orale, minzionali in modo indipendente, deambulazione in modo indipendente, e tollerare l&#39;assunzione di cibo per via orale. </li></ol>

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Eric Deshaies è un consulente medico per MicroVention, Covidien neurovascolare, Integra LifeSciences Corporation.

Clip chirurgica legatura di aneurismi intracranici rimane un&#39;opzione rilevante e importante nel trattamento di alcuni tipi di aneurismi, anche se questo ruolo è stato diminuendo nel corso degli ultimi anni, come la tecnologia endovascolare diventa più sicuro e più efficace. Il trattamento endovascolare ha superato un intervento chirurgico per aneurismi cerebrali, ma il tasso di recidiva più alto dopo il trattamento endovascolare, la necessità occasionale per il trattamento chirurgico dopo aneurisma recidiva dal...

Clip chirurgica legatura era stato il cardine del trattamento per aneurismi intracranici, ma è stato recentemente soppiantato lo più da tecniche endovascolari meno invasive. 1,2 Gli studi clinici, tra cui lo Studio Internazionale di non rotto intracraniche aneurismi (ISUIA-1 e ISUIA-2), e l&#39;International Subarachnoid Aneurysm Trial (ISAT) hanno dimostrato una minore morbilità e mortalità, riduzione della durata del soggiorno in ospedale, e la spesa complessiva inferiore, con trattamento endovascolare rispetto al chirurgico clip di legatura. 3 - 5 Tuttavia, il più alto tasso di recidiva dell&#39;aneurisma dopo la terapia endovascolare ha portato alla esame del rischio cumulativo per i pazienti rispetto ai chirurgica fermaglio legatura. 3,4 trattamento chirurgico rimane una modalità importante per la terapia aneurisma, in particolare per aneurismi circolazione anteriore che hanno morfologie che possono essere difficili da trattare con mezzi endovascolari. <p class = &quot;jove_content&quot;&gt; A differenza di avanzamenti nei dispositivi endovascolari, pochi progressi delle tecniche chirurgiche sono state effettuate di recente. Le tecniche per rendere il trattamento chirurgico meno invasivo hanno incluso la craniotomia sopraorbitali combinato con l&#39;incisione sopracciglio per aneurismi circolazione anteriore e &quot;chirurgia retractorless&quot; per ridurre al minimo il trauma chirurgico al cervello durante aneurisma ritaglio 6 -. 8 Questi approcci chirurgici meno invasivi possono ridurre la lunghezza di ospedale stare, la morbilità chirurgica, costo di trattamento, e migliorare i risultati dei pazienti. 9 Qui vi presentiamo la nostra esperienza con un approccio mini-invasivo di chirurgia clip di legatura degli aneurismi intracranici unruptured utilizzando un approccio pterional per anteriori circolazione aneurismi eseguite in un importante centro cerebrovascolare terziario e confrontare i risultati con un&#39;età abbinati dataset dal Nationwide ospedaliera di esempio (NIS ). La tecnica chirurgica sarà rivisto, Compresa la preparazione del paziente, il rilassamento del cervello, Sylvian fessura dissezione, e la chiusura. Saranno inoltre illustrati i requisiti di assistenza e di scarico post-operatorie.

<table><tbody><tr><td>Mayfield Infinity skull clamp</td><td>Integra</td><td>A-1114</td><td></td></tr><tr><td>Mayfield table attachment</td><td>Integra</td><td>A-1018</td><td></td></tr><tr><td>4-French Fukishima suction tip</td><td>Integra</td><td>R-8986</td><td></td></tr><tr><td>Periosteal elevator (Langenbeck)</td><td>Codman</td><td>65-1116</td><td></td></tr><tr><td>Metzenbaum scissors</td><td>Codman</td><td>36-5023</td><td></td></tr><tr><td>Malis dissector, round angled</td><td>Codman</td><td>80-1541&amp;nbsp;</td><td></td></tr><tr><td>Penfield dissector, style 1</td><td>Codman</td><td>65-1015</td><td></td></tr><tr><td>Lempert bone rongeur</td><td>Codman</td><td>19-1232</td><td></td></tr><tr><td>Malis Irrigation Module</td><td>Codman</td><td>Module 1000</td><td></td></tr><tr><td>Bovie monopolar electrocautery device</td><td>Codman</td><td></td><td></td></tr><tr><td>Insulated blade for electrocautery device</td><td>Covidien</td><td>E1455</td><td></td></tr><tr><td>Fish-hook retractors</td><td>Lone Star</td><td>3350-8G</td><td></td></tr><tr><td>Pneumatic drill</td><td>Medtronic</td><td>Midas Rex MR7</td><td></td></tr><tr><td>Side-cutting drill</td><td>Medtronic</td><td>F2/8TA23</td><td></td></tr><tr><td>Fluted legend match head tool</td><td>Medtronic</td><td>10MH30</td><td></td></tr><tr><td>Surgical scalpel No. 10, 11, 15</td><td>Bard-Parker</td><td>0029064 (No.10), 0018291 (No.11), 0018043 (No.15)</td><td></td></tr><tr><td>Intra-operative microscope with mouthpiece</td><td>Leica</td><td></td><td></td></tr><tr><td>Microscissors</td><td>V. Mueller</td><td>NL3785-034(st), NL3785-035(cvd)</td><td></td></tr><tr><td>Rhoton dissector, #2</td><td>V. Mueller</td><td>NL3785-002&amp;nbsp;</td><td></td></tr><tr><td>Telfa strips</td><td>American Surgical</td><td>#80-09 (1/2x3), #80-04 (1/4x3)</td><td></td></tr><tr><td>Aneurysm clip</td><td>Aesculap</td><td></td><td></td></tr><tr><td>Raney clip applier</td><td>Aesculap</td><td>FF012R</td><td></td></tr><tr><td>Synthes Matrix metal plating system</td><td>Synthes</td><td></td><td></td></tr><tr><td>Braided absorbable surgical sutures (Vicyrl)&amp;nbsp;</td><td>Ethicon</td><td>J790D (3-0), J743D (4-0)</td><td></td></tr><tr><td>Braided nylon nonabsorbable surgical sutures (Nurolon) 4-0</td><td>Ethicon</td><td>C584D</td><td></td></tr><tr><td>Doppler System</td><td>Mizuho</td><td>07-150-02</td><td></td></tr></tbody></table>

minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms

Approcci chirurgici meno invasivi per intracranica aneurisma ritaglio possono ridurre la durata del soggiorno in ospedale, la morbilità chirurgica, costo di trattamento, e migliorare i risultati dei pazienti. Vi presentiamo la nostra esperienza con un approccio mini-invasivo per pterional anteriori circolazione aneurismi eseguite in un importante centro cerebrovascolare terziario e confrontare i risultati con un set di dati abbinato di età compresa tra Nationwide ospedaliera di esempio (NIS). Da agosto 2008 a dicembre 2012, 22 ritagli aneurisma elettive in pazienti ≤55 anni di età sono stati eseguiti dallo stesso duplice fellowship addestrati cerebrovascolari / neurochirurgo endovascolare. Un paziente (4,5%) ha sperimentato transitori complicanze post-operatorie. 18 dei 22 pazienti tornati per il follow-up di immagini e non c&#39;erano recidive attraverso una durata media di 22 mesi. Una ricerca nel database di NIS 2008-2010, anche per i pazienti con età ≤55 anni di età, ha prodotto 1.341 ricoveri per chirurgico clip di legatura di unruptaneurismi cerebrali Ured. Lunghezza ospedaliera di soggiorno e le spese ospedaliere presso il nostro istituto con il mini-invasiva tecnica pterional pollice dimensioni erano circa la metà di quella di NIS (durata del soggiorno: 3,2 contro 5,7 giorni; le spese ospedaliere: $ 52.779 vs $ 101.882). Il mini-invasiva pollice dimensioni craniotomia pterional consente una buona esposizione di piccole e medie imprese sopraclinoidea aneurismi circolazione anteriore unruptured. Il drenaggio del liquido cerebrospinale dai principali cisterne subaracnoidea e costanti tecniche microchirurgiche bimanuali evitare la necessità di avvolgitori che possono causare contusioni, infarti venose localizzate, e post-operatoria edema cerebrale nei siti retrattore. Utilizzando questo insieme di tecniche ha offerto i nostri pazienti con una degenza ospedaliera più breve ad un costo inferiore rispetto alla media nazionale.

Attualmente, presso il nostro istituto oltre 150 aneurismi sono trattati ogni anno. Da agosto 2008 a dicembre 2012, 22 ritagli di aneurisma elettive che utilizzano questa tecnica mini-invasiva craniotomia pterional pollice dimensioni per aneurismi supraclinoidal sul paziente ≤55 anni di età sono stati eseguiti dallo stesso duplice fellowship addestrati cerebrovascolari / neurochirurgo endovascolare che ha sviluppato questa tecnica (EMD ) (Tabella 1). Questo gruppo di età è stata scelta come studi p...

Watch this Scientific Journal Video about Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms at JoVE.com

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Minimamente invasiva craniotomia pterional pollice dimensioni da aneurisma clipping ha offerto i nostri pazienti con una degenza ospedaliera più breve ad un costo inferiore rispetto alla media nazionale.

Minimamente invasiva Thumb dimensioni Pterional Craniotomy per chirurgica legatura della clip di non rotto Anteriori aneurismi circolazione

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

minimally-invasive-thumb-sized-pterional-craniotomy-for-surgical-clip

Research

JoVE Journal

Medicine

15.4K Views.  Crouse Neuroscience Institute.  Minimamente invasiva craniotomia pterional pollice dimensioni da aneurisma clipping ha offerto i nostri pazienti con una degenza ospedaliera più breve ad un costo inferiore rispetto alla media nazionale. 

Video: Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

La decompressione microvascolare: Principi salienti chirurgici e sfumature tecniche

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

Ricerca

Medicina

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection

Stroke is a leading cause of death, disability, and socioeconomic loss worldwide. The majority of all strokes result from an interruption in blood flow (ischemia) 1. Middle cerebral artery (MCA) delivers a great majority of blood to the lateral surface of the cortex 2, is the most common site of human stroke 3, and ischemia within its territory can result in extensive dysfunction or death 1,4,5. Survivors of ischemic stroke often suffer loss or disruption of motor capabilities, sensory deficits, and infarct. In an effort to capture these key characteristics of stroke, and thereby develop effective treatment, a great deal of emphasis is placed upon animal models of ischemia in MCA.
Here we present a method of permanently occluding a cortical surface blood vessel. We will present this method using an example of a relevant vessel occlusion that models the most common type, location, and outcome of human stroke, permanent middle cerebral artery occlusion (pMCAO). In this model, we surgically expose MCA in the adult rat and subsequently occlude via double ligature and transection of the vessel. This pMCAO blocks the proximal cortical branch of MCA, causing ischemia in all of MCA cortical territory, a large portion of the cortex. This method of occlusion can also be used to occlude more distal portions of cortical vessels in order to achieve more focal ischemia targeting a smaller region of cortex. The primary disadvantages of pMCAO are that the surgical procedure is somewhat invasive as a small craniotomy is required to access MCA, though this results in minimal tissue damage. The primary advantages of this model, however, are: the site of occlusion is well defined, the degree of blood flow reduction is consistent, functional and neurological impairment occurs rapidly, infarct size is consistent, and the high rate of survival allows for long-term chronic assessment.

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection

We describe a highly reproducible method for the permanent occlusion of a rodent major cerebral blood vessel. This technique can be accomplished with very little peripheral damage, minimal blood loss, a high rate of long-term survival, and consistent infarct volume commensurate with the human clinical population.

Cerebrale permanente occlusione di vasi<em&gt; Via</em&gt; Doppio Legatura e resezione

Stroke is a leading cause of death, disability, and socioeconomic loss worldwide. The majority of all strokes result from an interruption in blood flow ...

Microsurgical Clip Obliteration of Middle Cerebral Aneurysm Using Intraoperative Flow Assessment

Cerebral aneurysms are abnormal widening or ballooning of a localized segment of an intracranial blood vessel.  Surgical clipping is an important treatment for aneurysms which attempts to exclude blood from flowing into the aneurysmal segment of the vessel while preserving blood flow in a normal fashion.  Improper clip placement may result in residual aneurysm with the potential for subsequent aneurysm rupture or partial or full occlusion of distal arteries resulting in cerebral infarction.  Here we describe the use of an ultrasonic flow probe to provide quantitative evaluation of arterial flow before and after microsurgical clip placement at the base of a middle cerebral artery aneurysm.  This information helps ensure adequate aneurysm reconstruction with preservation of normal distal blood flow.

Description of the surgical obliteration of a cerebral aneurysm utilizing an ultrasonic flow probe to assess arterial flow prior to and after aneurysm clip placement.

Microchirurgico Obliteration clip del Medio aneurisma cerebrale mediante valutazione del flusso intraoperatoria

Cerebral aneurysms are abnormal widening or ballooning of a localized segment of an intracranial blood vessel.  Surgical clipping is an important ...

Biologia

Lateral Chronic Cranial Window Preparation Enables In Vivo Observation Following Distal Middle Cerebral Artery Occlusion in Mice

Focal cerebral ischemia (i.e., ischemic stroke) may cause major brain injury, leading to a severe loss of neuronal function and consequently to a host of motor and cognitive disabilities. Its high prevalence poses a serious health burden, as stroke is among the principal causes of long-term disability and death worldwide1. Recovery of neuronal function is, in most cases, only partial. So far, treatment options are very limited, in particular due to the narrow time window for thrombolysis2,3. Determining methods to accelerate recovery from stroke remains a prime medical goal; however, this has been hampered by insufficient mechanistic insights into the recovery process. Experimental stroke researchers frequently employ rodent models of focal cerebral ischemia. Beyond the acute phase, stroke research is increasingly focused on the sub-acute and chronic phase following cerebral ischemia. Most stroke researchers apply permanent or transient occlusion of the MCA in mice or rats. In patients, occlusions of the MCA are among the most frequent causes of ischemic stroke4. Besides proximal occlusion of the MCA using the filament model, surgical occlusion of the distal MCA is probably the most frequently used model in experimental stroke research5. Occlusion of a distal (to the branching of the lenticulo-striate arteries) MCA branch typically spares the striatum and primarily affects the neocortex. Vessel occlusion can be permanent or transient. High reproducibility of lesion volume and very low mortality rates with respect to the long-term outcome are the main advantages of this model. Here, we demonstrate how to perform a chronic cranial window (CW) preparation lateral to the sagittal sinus, and afterwards how to surgically induce a distal stroke underneath the window using a craniotomy approach. This approach can be applied for sequential imaging of acute and chronic changes following ischemia via epi-illuminating, confocal laser scanning, and two-photon intravital microscopy.

Lateral Chronic Cranial Window Preparation Enables In Vivo Observation Following Distal Middle Cerebral Artery Occlusion in Mice

Surgical occlusion of a distal middle cerebral artery branch (MCAo) is a frequently used model in experimental stroke research. This manuscript describes the basic technique of permanent MCAo, combined with the insertion of a lateral cranial window, which offers the opportunity for longitudinal intravital microscopy in mice.

Laterale cronica cranica finestra Preparazione Attiva<em&gt; In Vivo</em&gt; Condizioni seguito distale Medio occlusione dell&#39;arteria cerebrale nei topi

Focal cerebral ischemia (i.e., ischemic stroke) may cause major brain injury, leading to a severe loss of neuronal function and consequently to a host of ...

Neuroscienze

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs must be tailored specifically to the lesion, with surgical resection being the gold standard for small, accessible lesions. Pre-operative embolization of AVMs can reduce nidal blood flow and remove high-risk AVM features such as intranidal or venous aneurysms, thereby simplifying a challenging neurosurgical procedure. Herein, we describe our approach for the staged endovascular embolization and open resection of AVMs, and highlight the advantages of having a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team. This includes planning the craniotomy and resection to immediately follow the final embolization stage, thereby using a single session of anesthesia for aggressive embolization, and rapid resection. Finally, we provide a representative case of a 22-year-old female with an unruptured right frontal AVM diagnosed during a seizure workup, who was successfully treated via staged embolizations followed by open surgical resection.

Surgery is the gold standard for accessible arteriovenious malformations (AVMs), and pre-operative embolization can simplify this procedure. We describe our approach for staged endovascular embolization and open resection of AVMs, and provide a representative clinical example highlighting the advantages of a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team.

Endovascular completa e aprire Gestione chirurgica delle malformazioni arterovenose cerebrali

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs ...

Surgical Approach for Middle Cerebral Artery Occlusion and Reperfusion Induced Stroke in Mice

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ischemic in origin and occur in the territory of the middle cerebral artery (MCA). Currently the only Food and Drug Administration (FDA) approved drug for the treatment of this devastating disease is tissue plasminogen activator (tPA). However, tPA has a small therapeutic window for administration (3 - 6 hr), and is only effective in 4% of the patients who actually receive it. Current research focuses on understanding the pathophysiology of stroke in order to find potential therapeutic targets. Thus, reliable models are crucial, and the MCA occlusion (MCAo) model (also termed the intraluminal filament or suture model) is deemed to be the most clinically relevant surgical model of ischemic stroke, and is fairly non-invasive and easily reproducible. Typically the MCAo model is used with rodents, especially with mice due to all the genetic variations available for this species. Here we describe (and present in the video) how to successfully perform the MCAo model (with reperfusion) in mice to generate reliable and reproducible data.

In order to understand the pathophysiology of stroke, it is important to use reliable models. This paper will describe one of the most frequently used stroke models in mice, termed the middle cerebral artery occlusion (MCAo) model (also termed the intraluminal filament or suture model) with reperfusion.

Approccio chirurgico per occlusione dell&#39;arteria cerebrale media e riperfusione indotta ictus nei topi

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ...

Development of a Cadaveric Multiport Model of Posterior Circulation Aneurysm Clipping for Neurosurgery and Otolaryngology Residents

Posterior circulation aneurysms are difficult to treat with the current methods of coiling and clipping. To address limitations in training, we developed a cadaveric model to train learners on endoscopic clipping of posterior circulation aneurysms. An endoscopic transclival approach (ETA) and a transorbital precaruncular approach (TOPA) to successfully access and clip aneurysms of the posterior circulation are described. The model has flexibility in that a colored silicone compound can be injected into the cadaveric vessels for the purpose of training learners on vascular anatomy. The other option is that the model could be connected to a vascular perfusion pump allowing real-time appreciation of a pulsatile or ruptured aneurysm. This cadaveric model is the first of its kind for training of endoscopic clipping of posterior circulation aneurysms. Learners will develop proficiency in endoscopic skills, appropriate dissection, and appreciation for relative anatomy while developing an algorithm that can be employed in a real operative arena. Going forward, various clinical scenarios can be developed to enhance the realism, allow learners from different specialties to work together, and emphasize the importance of teamwork and effective communication.

A model protocol to train neurosurgery and otolaryngology resident learners on endoscopic transclival clipping of posterior circulation aneurysms is described. Two endoscopic approaches to access the silicone-injected or perfused posterior circulation of cadaveric heads are established for training. Learners are tasked with clipping of posterior circulation based on clinical scenarios.

Posterior circulation aneurysms are difficult to treat with the current methods of coiling and clipping. To address limitations in training, we developed ...

Middle Cerebral Artery Occlusion Allowing Reperfusion via Common Carotid Artery Repair in Mice

The ischemic stroke is a major cause of adult long-term disability and death worldwide. The current treatments available are limited, with only tissue plasminogen activator (tPA) as an approved drug treatment to target ischemic strokes. Current research in the field of ischemic stroke focuses on better understanding the pathophysiology of stroke, to develop and investigate novel pharmaceutical targets. Reliable experimental stroke models are crucial for the progression of potential treatments. The middle cerebral artery occlusion (MCAO) model is clinically relevant and the most frequently used surgical model of ischemic stroke in rodents. However, the outcomes of this model, such as lesion volume, are associated with high levels of variability, particularly in mice. The alternative MCAO model described here allows the reperfusion of the common carotid artery (CCA) and the increased perfusion of the middle cerebral artery (MCA) territory, using a tissue pad with fibrinogen-based sealant to repair the vessel, and the improved welfare of the mice by avoiding external carotid artery (ECA) ligation. This reduces the reliance on the Circle of Willis, which is known to be highly anatomically variable in mice. Representative data show that using this alternative surgical approach decreases the variability in lesion volumes between the traditional MCAO approach and the alternative approach described here.

Intraluminal filament occlusion of the middle cerebral artery is the most frequently used in vivo model of experimental stroke in rodents. An alternative surgical approach to allow common carotid artery repair is performed here, which allows the reperfusion of the common carotid artery and a full reperfusion to the middle cerebral artery territory.

Occlusione dell'arteria cerebrale centrale consentendo di riperfusione tramite riparazione dell'arteria carotica comune nei topi

The ischemic stroke is a major cause of adult long-term disability and death worldwide. The current treatments available are limited, with only tissue ...

Creation of Two Saccular Elastase-Digested Aneurysms with Different Hemodynamics in One Rabbit

Preclinical animal models with hemodynamic, morphologic, and histologic characteristics close to human intracranial aneurysms play a key role in the understanding of the pathophysiological processes and the development and testing of new therapeutic strategies. This study aims to describe a new rabbit aneurysm model that allows the creation of two elastase-digested saccular aneurysms with different hemodynamic conditions within the same animal.
Five female New Zealand white rabbits with a mean weight of 4.0 (&#177; 0.3) kg and mean age of 25 (&#177;5) weeks underwent microsurgical stump and bifurcation aneurysm creation. One aneurysm (stump) was created by right common carotid artery (CCA) exposure at its origin at the brachiocephalic trunk. A temporary clip was applied at the CCA origin and another, 2 cm above. This segment was treated with a local injection of 100 U of elastase for 20 min. A second aneurysm (bifurcation) was created by suturing an elastase-treated arterial pouch into the end-to-side anastomosis of the right CCA to left CCA. Patency was controlled by fluorescence angiography immediately after creation.
The average duration of surgery was 221 min. The creation of two aneurysms in the same animal was successful in all rabbits without complication. All aneurysms were patent immediately after surgery except for one bifurcation aneurysm, which showed an extreme tissue reaction due to elastase incubation and an immediate intraluminal thrombosis. No mortality was observed during surgery and up to one-month follow-up. Morbidity was limited to a transient vestibular syndrome (one rabbit), which recovered spontaneously within one day.
Demonstrated here for the first time is the feasibility of creating a two-aneurysm rabbit model with stump and bifurcation hemodynamic characteristics and highly degenerated wall conditions. This model allows the study of the natural course and potential treatment strategies on the basis of aneurysm biology under different flow conditions.

This protocol describes the steps for the creation of a rabbit model with two elastase-digested aneurysms with different hemodynamics (stump and bifurcation constellation). This allows the testing of novel endovascular devices in aneurysms with different angioarchitecture and hemodynamic conditions within a single animal.

Creazione di due aneurismi digeriti con elastasi sacculare con emodinamica diversa in un coniglio

Preclinical animal models with hemodynamic, morphologic, and histologic characteristics close to human intracranial aneurysms play a key role in the ...

Optimization of the Longa Middle Cerebral Artery Occlusion Method for Complete Reperfusion

The middle cerebral artery occlusion model serves as the primary animal model for studying ischemic stroke. Despite being used in research for over three decades, its standardization remains inadequate. Predominantly conducted on rats and mice, the procedure poses challenges due to mice's smaller and more fragile nature. Unlike the Koizumi common carotid artery method, the Longa external carotid artery is the sole intraluminal filament stroke model ensuring complete reperfusion post-ischemia. This aspect holds critical significance for studies investigating reperfusion phenomena. The surgical modifications demonstrated in this article ensure continuous blood flow from the common carotid artery throughout the ischemic phase and after the reperfusion onset. The goal of these modifications is to selectively occlude the middle cerebral artery by keeping the perfusion uninterrupted in branches proximal to the middle cerebral artery during the ischemia period. Furthermore, the onset of reperfusion is sudden and can be precisely controlled, thereby modeling endovascular thrombectomy in human medicine more accurately. Our aim in presenting this comprehensive video article is to ease the training of new surgeons and promote the standardization of surgical procedures within the scientific community.

This protocol presents a step-by-step guide for researchers to perform the middle cerebral artery occlusion procedure on mice using the modified Longa external carotid artery method. Modifications presented in this article aim to increase the accuracy of middle cerebral artery occlusion and ensure complete reperfusion.

Ottimizzazione del metodo di occlusione dell'arteria cerebrale media Longa per la riperfusione completa

The middle cerebral artery occlusion model serves as the primary animal model for studying ischemic stroke. Despite being used in research for over three ...

Minimamente invasiva Thumb dimensioni Pterional Craniotomy per chirurgica legatura della clip di non rotto Anteriori aneurismi circolazione

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