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.

注：前にこの手順を実行するには、すべての必要な機関の承認と患者の同意を得ます。 1.手術手技<ol><li>全身麻酔で患者を誘導します。 </li><li>血圧モニタリング用ラジアル動脈ラインを配置します。 </li><li>手術室のテーブルの上に仰臥位で患者を配置します。 </li><li>ヘッドはpterional開頭ための標準的な技術を用いて、メイフィールドヘッドホルダーにクランプされた後、ヘッドが60度に配置された前 - 交通動脈瘤を除いて、天井に向かって同側にヘッドを30°-45°を配置大脳縦裂の両端のより良い視覚化のために可能にします。 </li><li>首の正中線を配置し、脳浮腫を予防し、その後、最高点、これを同側頬骨を配置するために頭を拡張するために頚静脈還流を最大化するために前方に翻訳前頭葉緩和とエルが可能になります開創器を使用することなく、解剖時の軌道屋根からevation。 </li><li>標準pterional頭皮切開の準備のために髪をクリップ。ヘアラインの後ろに2インチのストリップに約1を使用します。 </li><li>無菌皮膚をプリパレーションとケアの標準に応じて手術領域をドレープ。 </li><li>約3mm前方耳珠および頬骨の優れたエッジのレベルでそれを終了耳珠に向かって後方と下方に緩やかな曲線とヘアラインの後ろの頭皮の正中線から延びるpterionalアプローチのための標準的な曲線状の頭皮の切開を行います。優れた時間的な線の上と頭筋のレベルでの筋膜に頭蓋骨までこの切開を行います。 </li><li>バイポーラデバイスで頭皮止血のための電気焼灼を使用してください。 </li><li>ボビーモノポーラ電気メス装置を用いて頭蓋骨に頭筋を削減。 </li><li>に取り付けられた頭筋を維持する筋肉皮弁を上げます今の頭皮の下面。フィッシュフックは頭筋がモノポーラ電気メスと骨膜エレベーターの組み合わせを使用して、頭蓋骨から上昇した後、フラップを裏返すために使用されます。 </li><li>顔面神経の損傷を避けるために、頭皮と筋膜とsubfacsial脂肪パッドを維持、Metzenbaumはさみを使用して、筋肉皮弁の下面から無血管平面内で逆筋膜下切開を行います。 </li><li> 「スター」fishhooksでpterional領域を露出するために後方および下方に頭筋を固定します。 </li><li>湿ったガーゼで湿った筋肉皮弁のすべてのコンポーネントを保管してください。 </li><li>サイドカットドリルのフットプレートが、この穴に挿入した後、サイドカットドリルを使用することができるように、2ミリメートルの切断バリでの計画開頭手術の後、大部分の側面に単一の時間的、5mmのバリ穴を開け親指サイズ（約3×4センチ）腎臓形開頭CENTEを除去するためのフットプレート付きプテリオン周りに前方に赤。 </li><li>第1ペンフィールドを使用して、プテリオンのすべての側面に硬膜を分離し、静かに離れて硬膜を貫通し、皮質の損傷を引き起こす危険性を最小限にするために掘削された骨表面からの硬膜を撤回アシスタントを持っています。 </li><li>ドリルでプテリオンを削除します。前方に、軌道屋根の優れたおよび横方向の側面が滑らかであり、subfrontal露出を最大化するために、軌道に入ることなく、骨の外側皮質テーブルまで平坦化されるまで、内側、上眼窩裂の硬膜までドリルを露出させ、ドリルビットまたは手持ちLempert骨切断装置のいずれかを使用して、内側の暴露を妨げる骨の任意の小片を削除しています。すべての軟部組織および骨表面の優れた止血が硬膜を開く前に、必要に応じてelectrocaurteryと骨ワックスを使用して、脳の解剖や動脈瘤の露光中に硬膜内空間に滴下血液を回避するために得られていることを確認してください。 </li><li>静かに硬膜を上げ、硬膜を貫通した後、プテリオンの塩基との硬膜中の「C字形」の開口部を作成するために硬膜はさみを使用する11番メスを使用しています。その近位シルビウス裂とsubfrontal地域の他の方法で曖昧な視覚化あろう冗長硬膜チラシがなくても、軌道の外側皮質骨に対して平ら硬膜を固定します。これは、頭皮に硬膜をタックSurgilons 4-0縫合糸を用いて行うことができます。 </li></ol> 2.脳リラクゼーション<ol><li>麻酔は、血圧が利尿を許容することに同意した場合、脳をリラックスして骨弁除去の時にマンニトール25〜50 gを得。 注：これは、利尿が発生するための時間を可能にし、最終的には、解剖時に重力に依存する脳の収縮を最大限にするために、脳をリラックスします。 </li><li>わずかhypercapneaを達成するために30〜35ミリメートルHgの間の呼吸終期のpCO 2を保管してください。注：これは、安全に、脳のリラックスとMAを可能にします解剖時に重力依存脳の収縮をximize。 </li><li>希望の脳の緩和が達成されるまでinteroptic、頸動脈光学、および頸動脈 - 動眼水槽にくも膜水槽を開き、辛抱強く吸引CSFによって脳の緩和を促進するために、脳脊髄液（CSF）を避難させます。 注：これは典型的には約1分かかります。何腰椎ドレインは、この技術では必要ありません、それは劇的に外科的回廊を開きます。 </li></ol> 3.シルビウス裂解剖<ol><li>無菌技術を使用して、フィールドに、マウスピースを術中顕微鏡を持参してください。また、両手器用さを最大化し、外科医の腕や手の疲労を防止するために、無菌フィールドに腕をサポートした手術用椅子を持参。 注：マウスピースは同時に眼の作品を見ながら、外科医は口で顕微鏡を移動させることができるように立体裁断前に調整する必要があります。 </li><li>解剖を行います。 注：について動脈瘤を伝える前方には、何のシルビウス裂郭清は必要ありませんし、最小限の（唯一の極端な場合2〜3ミリメートル、これはまれである）のみsubfrontal解剖を使用して必要とされていない状回の直筋切除することです。 （後部交通動脈を含む）他のすべてのsupraclinoid前方循環の動脈瘤の場所はsupraclinoid内頸動脈、その枝（後部が通信および脈絡膜動脈を前方）、内頸動脈の末端、A1とM1を露出するために、&lt;1cmの近位Sylivan割れ目郭清を必要とします起源、およびそれぞれの分岐に対して遠位、近位A2とM2セグメント。総シルビウス裂の露出はダイムサイズ（1センチ×1センチメートル）と全く脳のリトラクターが報告された症例のいずれにも使用されなかったありました。重力に依存する脳の緩和は、前述の領域に外科手術用クリップの連結を実行するために必要な軟組織構造と血管系の優れた露光のために十分でした。 </li><li>両手manipulaを使用外科的microinstrumentsとンを静かにこの露光により、必要に応じて機器のハンドルまたは吸引装置のエッジに脇脳組織を保持し、くも膜廊下を開きます。 注：筆頭著者の好みは、非利き手で、鋭い解剖のための鈍的切開またはmicroscissorsため利き手バイポーラbayonettesに4 - フランスFukishima吸引チップを使用することです。湿らTelfaストリップは皮質損傷を防ぐために、操作部位で脳の表面上に配置されます。 Cottonoidsは、多くの場合、脳の表面に付着し、解剖の進行に伴い、軽度の皮質の損傷を引き起こすことなく、より深く、容易に進めることができません。 </li><li>範囲を調整し、フィールドに両手を維持しながら、必要に応じて長さを集中し、頻繁に手術用顕微鏡にマウスピースを使用してください。 </li><li>外科的回廊とCの自由な可視化を維持するために、非利き手で最も頻繁に吸引を使用して、標準的な方法で動脈瘤を確保SF。 </li><li>クリップを配置した後、流れを確認し、慎重に動脈瘤のネックと親血管を調べるために、フローの停止だけでなく、流入流出血管を確認するために、動脈瘤ドームの術中ドップラーを行います。我々は、動脈瘤および流入、流出、または動脈瘤の首を完全に可視化することができないか、術中ドップラーとの懸念があるそれらのクリップされた動脈瘤を通信するための前方術中デジタルサブトラクション血管造影（DSA）を確保します。多数の動脈瘤クリップを動脈瘤の頸部を再構築するために使用される場合、クリップは可視化を妨害することができるので、術中DSAは、インドシアニングリーン（ICG）血管造影法よりも好ましいです。注：動脈瘤がしっかり切り取られた後、顕微鏡視野から除去され、生理食塩水で灌注脳が閉鎖後pneumocephalusの量を最小限にします。 </li><li>ドップラーで動脈瘤の閉塞のためのクリップを検査した後、動脈瘤のドームは、穿孔ウィットあります<html> haの22 G針が静脈内チューブ、10 mlシリンジおよび動脈瘤の閉塞を確認するために吸引し、手動で吸引に添付します。 </li><li> 4-0 surgilonでネイティブ硬膜をReapproximateと水密閉鎖を適切に得ることができない場合は、合成硬膜代替でカバー。 </li><li>ケアの標準あたりの金属メッキシステムで骨プレートを固定します。 </li><li>組織が治癒した後に、化粧品として喜ばないであろう2の間にスペースを回避するために、ネイティブの骨に対する骨フラップフラッシュの正面端を固定します。 </li><li>中断2-0ビクリル縫合糸で頭筋の筋膜をReapproximate。優れた時間的なラインにreapproximateする前頭金属板に2-0ビクリルステッチと頭筋の上部を固定します。 </li><li> 3-0ビクリル縫合糸を使用してガレアをReapproximateやステープル、ナイロン、またはプロレンのいずれかを使用して標準的な方法で頭皮を閉じます。外科医の好みごとに滅菌包帯のドレス。 </li></ol>_title &quot;&gt; 4。後処理のケア<ol><li>治療後の集中治療室に患者を認めるとすぐに鎮静または全身麻酔は、典型的には、抜管の6時間以内に、これを行うには十分にオフに着用しているように看護スタッフと動員。 </li><li>看護スタッフによる任意の懸念があった場合に自宅に安全に排出するために患者を評価するために、術後初日を開始するために、物理的および作業療法を注文。 </li><li>唯一の経口薬、独立して、排尿独立ambulating、および経口食物摂取を許容して制御痛み：基準が満たされている患者を放電します。 </li></ol>

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	<li>Guglielmi, G., Vi&#241;uela, F., Dion, J., Duckwiler, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electrothrombosis+of+saccular+aneurysms+via+endovascular+approach.+Part+2:+Preliminary+clinical+experience.">Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience.</a> Journal of neurosurgery. 75 (1), 8-14 (1991).</li><li>Hoh, B. L., Chi, Y. -. Y., Dermott, M. A., Lipori, P. J., Lewis, S. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+coiling+versus+clipping+of+ruptured+and+unruptured+cerebral+aneurysms+on+length+of+stay,+hospital+cost,+hospital+reimbursement,+and+surgeon+reimbursement+at+the+university+of+Florida.">The effect of coiling versus clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the university of Florida.</a> Neurosurgery. 64 (4), 614-619 (2009).</li><li>Wiebers, D. O., Whisnant, J. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Unruptured+intracranial+aneurysms:+natural+history,+clinical+outcome,+and+risks+of+surgical+and+endovascular+treatment.">Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment.</a> Lancet. 362 (9378), 103-110 (2003).</li><li>Molyneux, A., Kerr, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+Subarachnoid+Aneurysm+Trial+(ISAT)+of+neurosurgical+clipping+versus+endovascular+coiling+in+2143+patients+with+ruptured+intracranial+aneurysms:+a+randomised+trial.">International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial.</a> Lancet. 360 (9342), 1267-1274 (2002).</li><li>Spetzler, R. F., McDougall, C. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Barrow+Ruptured+Aneurysm+Trial:+3-year+results.">The Barrow Ruptured Aneurysm Trial: 3-year results.</a> Journal of neurosurgery. , (2013).</li><li>Spetzler, R. F., Sanai, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+quiet+revolution:+retractorless+surgery+for+complex+vascular+and+skull+base+lesions.">The quiet revolution: retractorless surgery for complex vascular and skull base lesions.</a> Journal of neurosurgery. 116 (2), 291–-300 (2012).</li><li>Chalouhi, N., Jabbour, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+ruptured+anterior+circulation+aneurysms:+comparison+of+pterional+and+supraorbital+keyhole+approaches.">Surgical treatment of ruptured anterior circulation aneurysms: comparison of pterional and supraorbital keyhole approaches.</a> Neurosurgery. 72 (3), 437-441 (2013).</li><li>Petraglia, A. L., Srinivasan, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Unilateral+subfrontal+approach+to+anterior+communicating+artery+aneurysms:+A+review+of+28+patients.">Unilateral subfrontal approach to anterior communicating artery aneurysms: A review of 28 patients.</a> Surgical neurology international. 2, 124 (2011).</li><li>Goettel, N., Chui, J., Venkatraghavan, L., Tymianski, M., Manninen, P. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Day+Surgery+Craniotomy+for+Unruptured+Cerebral+Aneurysms:+A+Single+Center+Experience.">Day Surgery Craniotomy for Unruptured Cerebral Aneurysms: A Single Center Experience.</a> Journal of neurosurgical anesthesiology. , (2013).</li><li>Andaluz, N., Zuccarello, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recent+trends+in+the+treatment+of+cerebral+aneurysms:+analysis+of+a+nationwide+inpatient+database.">Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database.</a> Journal of neurosurgery. 108 (6), 1163-1169 (2008).</li><li>Barker, F. G., Amin-Hanjani, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Age-dependent+differences+in+short-term+outcome+after+surgical+or+endovascular+treatment+of+unruptured+intracranial+aneurysms+in+the+United+States.">Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States.</a> Neurosurgery. 54 (1), 18-28 (1996).</li><li>Cowan, J. A., Ziewacz, J., Dimick, J. B., Upchurch, G. R., Thompson, B. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+endovascular+coil+embolization+and+surgical+clip+occlusion+for+cerebral+artery+aneurysms.">Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms.</a> Journal of neurosurgery. 107 (3), 530-535 (2007).</li><li>Crowley, R. W., Yeoh, H. K., Stukenborg, G. J., Ionescu, A. A., Kassell, N. F., Dumont, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Influence+of+weekend+versus+weekday+hospital+admission+on+mortality+following+subarachnoid+hemorrhage.+Clinical+article.">Influence of weekend versus weekday hospital admission on mortality following subarachnoid hemorrhage. Clinical article.</a> Journal of neurosurgery. 111 (1), 60-66 (2009).</li><li>Hoh, B. L., Chi, Y. -. Y., Lawson, M. F., Mocco, J., Barker, F. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Length+of+stay+and+total+hospital+charges+of+clipping+versus+coiling+for+ruptured+and+unruptured+adult+cerebral+aneurysms+in+the+Nationwide+Inpatient+Sample+database+2002+to+2006.">Length of stay and total hospital charges of clipping versus coiling for ruptured and unruptured adult cerebral aneurysms in the Nationwide Inpatient Sample database 2002 to 2006.</a> Stroke; a journal of cerebral circulation. 41 (2), 337-342 (2010).</li><li>Hoh, B. L., Rabinov, J. D., Pryor, J. C., Carter, B. S., Barker, F. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=In-hospital+morbidity+and+mortality+after+endovascular+treatment+of+unruptured+intracranial+aneurysms+in+the+United+States,+1996-2000:+effect+of+hospital+and+physician+volume.">In-hospital morbidity and mortality after endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000: effect of hospital and physician volume.</a> AJNR. American journal of neuroradiology. 24 (7), 1409-1420 (2003).</li><li>Shea, A. M., Reed, S. D., Curtis, L. H., Alexander, M. J., Villani, J. J., Schulman, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Characteristics+of+nontraumatic+subarachnoid+hemorrhage+in+the+United+States+in+2003.">Characteristics of nontraumatic subarachnoid hemorrhage in the United States in 2003.</a> Neurosurgery. 61 (6), 1131-1137 (2007).</li><li>Rodr&#237;guez-Hern&#225;ndez, A., Sughrue, M. E., Akhavan, S., Habdank-Kolaczkowski, J., Lawton, M. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+management+of+middle+cerebral+artery+aneurysms:+surgical+results+with+a+&#8220;clip+first&#8221;+policy.">Current management of middle cerebral artery aneurysms: surgical results with a &#8220;clip first&#8221; policy.</a> Neurosurgery. 72 (3), 415-427 (2013).</li><li>Van Lindert, E., Perneczky, A., Fries, G., Pierangeli, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+supraorbital+keyhole+approach+to+supratentorial+aneurysms:+concept+and+technique.">The supraorbital keyhole approach to supratentorial aneurysms: concept and technique.</a> Surgical neurology. 49 (5), 489-490 (1998).</li><li>Dott, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intracranial+aneurysms:+cerebral+arteriography:surgical+treatment.">Intracranial aneurysms: cerebral arteriography:surgical treatment.</a> Edinb Med J. 40, 219-234 (1933).</li><li>Dandy, W. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aneurysm+of+the+anterior+cerebral+artery.">Aneurysm of the anterior cerebral artery.</a> Journal of the American Medical Association. 119 (16), 1253-1254 (1942).</li><li>Yasargil, M., Fox, J., Ray, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+operative+approach+to+aneurysms+of+the+anterior+communicating+artery.">The operative approach to aneurysms of the anterior communicating artery.</a> Advances and Technical Standards in Neurosurgery. 2, 113-170 (1975).</li><li>Al-Mefty, O., Fox, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Superolateral+orbital+exposure+and+reconstruction.">Superolateral orbital exposure and reconstruction.</a> Surgical neurology. 23 (6), 609-613 (1985).</li><li>Heros, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+supraorbital+&#8220;keyhole&#8221;+approach.">The supraorbital &#8220;keyhole&#8221; approach.</a> Journal of neurosurgery. 114 (3), 850-851 (2011).</li></ol>

エリックDeshaiesのはMicroVention、コヴィディエン神経血管、インテグラライフサイエンス社の医師のコンサルタントです。

血管内技術は、より安全でより効果的になるように、この役割は過去数年間で減少したが、頭蓋内動脈瘤の外科用クリップの連結は、動脈瘤の特定の種類の治療に関連する重要なオプションのまま。血管内治療は、脳動脈瘤の手術を超えている、まだ血管内治療後の高い再発率は、失敗した血管内治療から動脈瘤の再発後の外科的治療のための臨時の必要性は、特定の形態は、ステント留置?...

外科用クリップの連結は、脳動脈瘤の治療の主力であったが、最近、低侵襲性血管内の技術によって主に取って代わられている。 未破裂脳動脈瘤の国際研究（ISUIA-1とISUIA-2）、および国際含め1,2臨床試験くも膜下動脈瘤トライアル（ISAT）は 、外科手術用クリップライゲーションに比べて血管内治療と、より低い罹患率および死亡率、入院期間の長さを短くし、より低い全体の費用を示した。3 - 5しかし、血管内治療後の高い動脈瘤の再発率がにつながっています患者への累積リスクの検査は、外科手術用クリップのライゲーションに比べて。3,4外科的治療は、特に血管内の手段で治療が困難であってもよい形態を持って前方循環動脈瘤のために、動脈瘤の治療のための重要な様式のままです。 6 - 8これらの侵襲性の低い外科的アプローチは、病院の長さを減少させることができます滞在、外科的罹患率、治療費、および患者の予後を改善する。9 ここでは、主要な第三脳血管センターで行わ前方循環動脈瘤のためpterionalアプローチを使用して未破裂脳動脈瘤の外科手術用クリップの結紮に低侵襲性アプローチの経験を提示し、加齢に伴って結果を比較全国入院患者のサンプルからのデータセットを一致（NIS ）。外科的技術が検討されます、患者の準備、脳緩和、シルビウス裂の解剖、および閉鎖を含みます。術後ケアおよび排出要件も概説します。

<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

頭蓋内動脈瘤クリッピングのための低侵襲性の外科的アプローチは、入院、手術用罹患率、治療費の長さを低減し、患者の転帰を改善することができます。我々は前方循環動脈瘤の主要な第三脳血管センターで行い、全国入院患者のサンプル（NIS）から経年マッチしたデータセットと結果を比較するための低侵襲性pterionalアプローチで我々の経験を提示します。 2008年8月から2012年12月に、患者の年齢の≤55年の22科目動脈瘤のクリッピングは、同じデュアル交わりのトレーニングを受けた脳血管/血管内神経外科医によって行われました。一人の患者（4.5％）は一過性術後合併症を経験しました。 22人の患者の18は、フォローアップのイメージングのために戻され、22ヶ月の平均期間を通る再発はなかったです。 2008年から2010年のNISデータベース内の検索は、また年齢の≤55歳の患者のために、unruptの外科用クリップの連結のために1341の入院をもたらしましたured脳動脈瘤。低侵襲性の親指サイズのpterional技術を用いて、当院での滞在と病院費用の入院の長されたほぼ半分にNISの（滞在の長さ：3.2 5.7対日、入院費：52779ドル対101882ドル）。低侵襲性の親指サイズのpterional開頭術は未破裂中小supraclinoid前方循環動脈瘤の良好な露出を可能にします。キーくも膜下水槽と一定両手顕微技術から脳脊髄液ドレナージは、開創サイトで挫傷、ローカライズされた静脈梗塞、および術後の脳浮腫を引き起こす可能性がリトラクターの必要性を回避します。技術のセットを利用することで、全国平均に比べて低いコストで、より短い入院で私たちの患者を与えています。

現在、私たちの施設で150人以上の動脈瘤は、毎年扱われます。 2008年8月から2012年12月に、年齢の患者の≤55年にsupraclinoidal動脈瘤のためにこの最小侵襲性の親指サイズのpterional開頭技術を用いて22科目動脈瘤のクリッピングは、この技術を開発し、同じデュアル交わりのトレーニングを受けた脳血管/血管内神経外科医（EMDによって行われました）（ 表1）。以前の試験は血管内治?...

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

動脈瘤クリッピングのための低侵襲性の親指サイズのpterional開頭術は、全国平均に比べて低いコストで、より短い入院で私たちの患者を与えています。

未破裂前方循環動脈瘤の外科手術用クリップの連結のための低侵襲親指サイズのPterional開頭術

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 ビュー.  Crouse Neuroscience Institute. 動脈瘤クリッピングのための低侵襲性の親指サイズのpterional開頭術は、全国平均に比べて低いコストで、より短い入院で私たちの患者を与えています。 

ビデオ: 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.

微小血管減圧術：顕著な外科手術の原則と技術的なニュアンス

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

医学

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.

永久的な脳血管閉塞<em&gt;経由</em&gt;ダブルリガチャーと離断

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.

術中フローアセスメントを用いた中大脳動脈瘤の顕微クリップ閉塞

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

生物学

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.

横慢性頭蓋窓の準備を有効<em&gt;インビボ</em&gt;マウスの遠位中大脳動脈閉塞後に観測

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 ...

神経科学

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.

包括的な血管内治療、脳動静脈奇形のオープン手術の管理

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.

マウスの中大脳動脈閉塞再灌流誘発性の脳卒中のための外科的アプローチ

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.

マウスにおける一般的な頸動脈の修理で再灌流を許可する中大脳動脈閉塞

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.

1匹のウサギにおける血行動態の異なる嚢状エラスターゼ消化動脈瘤の作製

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.

完全再灌流のためのLonga中大脳動脈閉塞法の最適化

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

未破裂前方循環動脈瘤の外科手術用クリップの連結のための低侵襲親指サイズのPterional開頭術

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