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: Antes de realizar este procedimento, obter toda a aprovação institucional necessária e consentimento do paciente. 1. Técnica Cirúrgica <ol><li> Induzir o paciente com a anestesia geral. </li><li> Coloque linha arterial radial para monitorização da pressão arterial. </li><li> Coloque paciente em decúbito dorsal sobre a mesa da sala de operação. </li><li> Após a cabeça é preso no porta-Mayfield Cabeça utilizando técnicas padrão para uma craniotomia pterional, posicionar a cabeça de 30 ° -45 ° com o lado ipsilateral para o teto, com exceção de aneurismas da artéria comunicante anterior na qual a cabeça é colocada em 60º para permitir melhor visualização através da fissura inter-hemisférica. </li><li> Posicione a linha média do pescoço e traduzir anteriormente para maximizar a drenagem venosa jugular para evitar edema cerebral e, em seguida, estender a cabeça para posicionar o zygoma ipsilateral ao mais alto ponto de este permite o relaxamento lobo frontal e elevation do telhado orbital durante a dissecção, sem a utilização de afastadores. </li><li> Prenda o cabelo em preparação para o padrão incisão no couro cabeludo pterional; utilizar cerca de um 1-2 tira polegadas atrás da linha fina. </li><li> Esterilmente preparar a pele e armar a área cirúrgica de acordo com padrão de atendimento. </li><li> Realizar uma incisão no couro cabeludo curva padrão para uma abordagem pterional se prolonga a partir da linha média do couro cabeludo para trás da linha do cabelo, com uma curva suave posteriormente e inferiormente para o trago terminando cerca de 3 mm anterior ao trago e ao nível da aresta superior do zygoma . Executar esta incisão para baixo para o crânio acima da linha temporal superior e para a fáscia muscular ao nível do músculo temporal. </li><li> Use eletrocautério para hemostasia couro cabeludo com o dispositivo bipolar. </li><li> Corte o músculo temporal até o crânio usando o aparelho de bisturi elétrico monopolar bovie. </li><li> Levante um retalho miocutâneo mantendo o músculo temporal ligado àinferior do couro cabeludo por enquanto. Anzóis são utilizados para o retalho everter após o músculo temporal é elevada a partir do crânio usando uma combinação de electrocautério monopolar e um elevador periosteal. </li><li> Executar uma dissecção subfascial inversa no plano avascular da superfície inferior do retalho miocutâneo usando uma tesoura Metzenbaum, mantendo a fáscia e almofada de gordura subfacsial com o couro cabeludo para evitar a lesão do nervo facial. </li><li> Prenda o músculo temporal posterior e inferiormente para expor a região pterional com &quot;estrela&quot; anzóis. </li><li> Mantenha todos os componentes do retalho miocutâneo úmido com gaze molhada. </li><li> Perfurar um único temporais 5 milímetros rebarba buracos no aspecto póstero-maior da craniotomia planejado com um corte de 2 milímetros rebarba para que o prato pé da broca de corte de lado pode ser inserido em um buraco e, em seguida, usar uma broca de corte de lado com uma placa do pé para remover o tamanho de um polegar (aproximadamente 3 x 4 cm) em forma de rim craniotomia centevermelho anteriormente em torno do pterígio. </li><li> Usando um No. 1 Penfield, separar a dura-máter em todos os lados do pterígio e tem um assistente retrair suavemente a dura-máter de distância a partir da superfície do osso que está a ser perfurado, para minimizar o risco de penetrar a dura-máter e causando lesão cortical. </li><li> Remover o ptério com uma broca: anteriormente, até que os aspectos superiores e laterais do telhado orbital são lisas e achatado para baixo para a mesa cortical exterior do osso, sem entrar na órbita, para maximizar a exposição subfrontal; medial, broca até a dura fissura orbital superior é exposta e remover quaisquer pequenos pedaços de ossos que possam interferir com a exposição medial usando uma broca ou dispositivo de corte de mão Lempert óssea. Certifique-se de que a excelente hemostasia de todas as superfícies dos tecidos moles e osso foi obtido para evitar o gotejamento do sangue para dentro do espaço intradural cérebro durante a dissecção e a exposição do aneurisma, utilizando electrocaurtery e cera de osso, conforme necessário, antes de abrir a dura-máter. </li><li>Suavemente elevar a dura-máter e usar um bisturi número 11 para penetrar na dura-máter e, em seguida, utilizar tesouras durais para criar uma abertura em forma de &quot;C&quot; na dura-máter com a base no ptério. Prenda o plano dura contra o osso cortical externo da órbita sem ter folhetos redundante dural que a visualização de outra forma obscura do proximal Sylvian Fissura e região subfrontal. Esta pode ser realizada utilizando 4-0 suturas Surgilons a aderência a dura-máter ao couro cabeludo. </li></ol> Relaxamento 2. Cérebro <ol><li> Dê 25-50 g de manitol no momento da remoção do retalho ósseo para relaxar o cérebro se anestesia concorda que a pressão arterial vai tolerar diurese. NOTA: Isto dará tempo para a diurese a ocorrer e, finalmente, vai relaxar o cérebro para ajudar a maximizar a gravidade dependente retração cerebral durante a dissecção. </li><li> Mantenha-End Tidal pCO 2 entre 30-35 mm Hg para alcançar ligeira hipercapnia. NOTA: Isto irá permitir com segurança para relaxamento cerebral e maximize gravidade dependente retração cerebral durante a dissecção. </li><li> Evacuar cisternas carótida-oculomotores líquido cefalorraquidiano (LCR) para promover o relaxamento do cérebro, abrindo as cisternas aracnóide na interoptic, carótida-óptico, e pacientemente e CSF sucção até se atingir o cérebro relaxamento desejado. NOTA: Isso normalmente leva cerca de 1 min; sem drenagem lombar é necessária com esta técnica e abre dramaticamente os corredores cirúrgicos. </li></ol> 3. Sylvian Fissura Dissection <ol><li> Traga o microscópio intra-operativa com o bocal para o campo usando técnicas estéreis. Também trazer cadeiras cirúrgicas com apoio de braço para o campo estéril para maximizar destreza bimanual e evitar cirurgião braço e fadiga de mão. NOTA: O bocal deve ser ajustado antes de drapejar de modo que o cirurgião pode mover o microscópio com a boca, ao mesmo tempo que olha através das peças oculares. </li><li> Realizar dissecção. NOTA: Paracomunicante anterior aneurismas da artéria, sem dissecção Sylvian Fissura é necessária e mínima (2-3 mm em apenas casos extremos, mas esta é uma ocorrência rara) para não ressecção giro reto é necessário usar dissecção única subfrontal; todos os outros locais circulação anterior aneurisma supraclinóidea (incluindo artéria comunicante posterior) exigem &lt;1 centímetro proximal Sylivan Fissura dissecção para expor a artéria carótida interna supraclinóidea, seus ramos (comunicante posterior e anterior artérias coróide), o terminal da artéria carótida interna, a A1 ea M1 origens, e proximal A2 e M2 segmentos distais às suas respectivas bifurcações. A exposição total Sylvian Fissura foi dime-size (um centímetro x 1 cm) e sem retratores cerebrais foram utilizados para qualquer um dos casos relatados. A gravidade depende relaxamento cérebro foi suficiente para excelente exposição das estruturas de tecidos moles e vasculatura necessários para executar cirúrgico pinça de aperto nas áreas discutidas acima. </li><li> Usando manipulações bimanualção com microinstrumentos cirúrgicos abrir suavemente os corredores aracnóide, segurando o tecido cerebral de lado com a borda do dispositivo alças de instrumentos ou de sucção, conforme necessário através desta exposição. NOTA: A preferência do autor sênior é usar uma ponta de aspiração 4-Francês Fukishima na mão não dominante e na mão bayonettes bipolares dominantes para dissecção romba ou microtesoura para dissecção afiada. Tiras humedecido Telfa são colocados na superfície do cérebro no local de manipulação para evitar lesões corticais. Cotonóides frequentemente aderir à superfície do cérebro e não pode ser facilmente avançada mais profunda quanto a dissecção progride, sem causar lesão cortical leve. </li><li> Use o bocal no microscópio cirúrgico com freqüência para ajustar o escopo e duração concentrar quando necessário, mantendo as duas mãos no campo. </li><li> Prenda o aneurisma em forma padrão, usando a aspiração na maioria das vezes na mão não dominante para manter o corredor cirúrgico e visualização livre de CSF. </li><li> Após a colocação do clipe, execute Doppler intra-operatório da cúpula aneurisma para confirmar cessação do fluxo, bem como os navios de entrada e de saída para confirmar o fluxo e examinar cuidadosamente os vasos do pescoço aneurisma e mãe. Reservamo-nos intra-operatória angiografia digital (DSA) para aneurismas da artéria comunicante anterior e os aneurismas cortadas onde ingresso, saída, ou aneurisma pescoço não podem ser visualizados completamente ou há uma preocupação com Doppler intra-operatório. DSA Intra-operatória é preferível a indocianina verde (ICG) angiografia porque quando vários clips de aneurisma são usados ​​para reconstruir o colo do aneurisma, o clipe pode obstruir visualização. Observação: Uma vez que o aneurisma tenha sido cortada de forma segura, o microscópio é removido do campo e do cérebro irrigado com solução salina normal, para minimizar a quantidade de Pneumoencéfalo após o encerramento. </li><li> Depois de inspecionar o clipe para a oclusão do aneurisma, com o Doppler, a cúpula aneurisma é sagacidade perfurada<html> ha 22 G agulha acoplada ao tubo intravenoso e uma seringa de 10 ml e manualmente sucção aspirada para confirmar a oclusão do aneurisma. </li><li> Reapproximate a dura nativa com 4-0 surgilon e cobrir com um substituto dural sintética se um fecho estanque não é capaz de ser obtido correctamente. </li><li> Placas ósseas seguras com um sistema de metalização por padrão de atendimento. </li><li> Fixar a borda frontal da aleta alinhada osso contra o osso nativo para evitar o espaço entre os dois o que não seria esteticamente agradável após os tecidos curar. </li><li> Reapproximate a fáscia do músculo temporal com suturas interrompidas 2-0 Vicryl. Fixar o topo do músculo temporal com um 2-0 Vicryl ponto para a placa metálica frontal a reapproximate-la na linha temporal superior. </li><li> Reapproximate o galea usando suturas Vicryl 3-0 e fechar o couro cabeludo de uma forma padrão usando grampos, nylon, ou prolene. Vestido com ligaduras estéreis por preferência do cirurgião. </li></ol>_title &quot;&gt; 4. Pós-tratamento Cuidados <ol><li> Admita paciente na unidade de terapia intensiva após o tratamento e mobilizar com a equipe de enfermagem, logo que sedação ou anestesia geral se esgotou o suficiente para fazê-lo, normalmente dentro de 6 horas de extubação. </li><li> Ordem física e terapia ocupacional para começar a pós-operatório, um dia, a fim de avaliar o paciente para a descarga segura para casa se houvesse qualquer preocupação por parte do pessoal de enfermagem. </li><li> Alta ao paciente quando são satisfeitos os critérios: dor controlada com apenas medicamentos orais, miccionais de forma independente, deambuladores de forma independente, e toleram a ingestão de alimentos por via oral. </li></ol>

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Eric Deshaies é um consultor médico para MicroVention, a Covidien neurovascular, Integra LifeSciences Corporation.

Surgical pinças de aperto de aneurismas intracranianos continua a ser uma opção relevante e importante no tratamento de certos tipos de aneurismas, embora esse papel tem vindo a diminuir ao longo dos últimos anos como a tecnologia endovascular torna-se mais seguro e mais eficaz. O tratamento endovascular tem superado a cirurgia para aneurismas cerebrais, no entanto, a maior taxa de recorrência após o tratamento endovascular, a eventual necessidade de tratamento cirúrgico após o retorno do tratamento endovascular...

Pinça de aperto cirúrgica tinha sido o pilar do tratamento de aneurismas intracranianos, mas foi recentemente suplantou em sua maioria por técnicas endovasculares menos invasivos. 1,2 ensaios clínicos, incluindo o Estudo Internacional de unruptured intracranianas aneurismas (ISUIA-1 e ISUIA-2), e da Internacional subaracnóide Aneurysm Trial (ISAT) demonstraram menor morbidade e mortalidade, reduziu o tempo de internação, ea despesa total mais baixo, com o tratamento endovascular em comparação com pinça de aperto cirúrgica 3 - 5. No entanto, a taxa de recorrência do aneurisma maior após terapia endovascular levou à análise do risco cumulativo para os pacientes em comparação com pinça de aperto cirúrgica 3,4. O tratamento cirúrgico continua a ser uma modalidade terapêutica importante para aneurisma, particularmente para aneurismas circulação anterior que possuem morfologias que podem ser difíceis de tratar com os meios endovasculares. <p class = &quot;jove_content&quot;&gt; Ao contrário de avanços em dispositivos endovasculares, poucos avanços nas técnicas cirúrgicas têm sido feitas recentemente. Técnicas para fazer o tratamento cirúrgico menos invasivo ter incluído a craniotomia supra-orbitária combinado com a incisão sobrancelha para aneurismas da circulação anterior e &quot;a cirurgia retractorless&quot; para minimizar o trauma cirúrgico para o cérebro durante a clipagem de aneurisma 6 -. 8 Estas abordagens cirúrgicas menos invasivas podem reduzir o tempo de internação ficar, a morbidade cirúrgica, o custo do tratamento e melhorar os resultados dos pacientes. 9 Aqui, apresentamos nossa experiência com uma abordagem minimamente invasiva para ligadura cirúrgica clipe de aneurismas intracranianos não rotos usando uma abordagem pterional para aneurismas da circulação anterior realizados em um grande centro terciário de cerebrovascular e comparar os resultados com uma idade combinado conjunto de dados do Nationwide Inpatient Sample (NIS ). A técnica cirúrgica será revisto, Incluindo a preparação do paciente, relaxamento cerebral, dissecção fissura Sylvian, e encerramento. De cuidados e de descarga requisitos pós-operatórias também será delineado.

<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

Abordagens cirúrgicas menos invasivas para clipagem de aneurisma intracraniano pode reduzir o tempo de internação, morbidade cirúrgica, o custo do tratamento e melhorar os resultados dos pacientes. Apresentamos nossa experiência com uma abordagem pterional minimamente invasiva para aneurismas da circulação anterior realizados em um grande centro terciário de cerebrovascular e comparar os resultados com um conjunto de dados combinados com idade a partir da amostra nacional Inpatient (NIS). De agosto de 2008 a dezembro de 2012, 22 de aneurisma recortes eletivas em pacientes ≤55 anos de idade foram realizadas pela mesma dupla bolsa-formados cerebrovascular / neurocirurgião endovascular. Um paciente (4,5%) apresentaram complicações pós-operatórias transitórios. 18 de 22 pacientes retornaram para a imagem latente seguimento e não houve recidivas através de uma duração média de 22 meses. Uma busca no banco de dados NIS 2008-2010, também para pacientes com idade ≤55 anos de idade, rendeu 1.341 hospitalizações por ligadura cirúrgica clipe de unruptaneurismas cerebrais ured. Comprimento de internação de estadia e hospitalares encargos em nossa instituição usando a técnica pterional tamanho de um polegar minimamente invasiva foram quase metade do NIS (duração da estadia: 3,2 vs 5,7 dias; despesas hospitalares: $ 52,779 vs. $ 101,882). A craniotomia pterional tamanho de um polegar minimamente invasiva permite uma boa exposição de unruptured pequenas e médias supraclinóidea aneurismas da circulação anterior. A drenagem do líquor de cisternas subaracnóideas-chave e técnicas de microcirurgia bimanuais constantes evitar a necessidade de afastadores que pode causar contusões, infartos venosos localizadas e edema cerebral pós-operatória nos locais retrator. Utilizando este conjunto de técnicas tem proporcionado nossos pacientes com menor tempo de internação a um custo menor em comparação com a média nacional.

Atualmente, em nossa instituição mais de 150 aneurismas são tratados anualmente. De agosto de 2008 a dezembro de 2012, 22 de aneurisma recortes eletivos usando esta técnica minimamente invasiva craniotomia pterional tamanho de um polegar para aneurismas supraclinoidal no paciente ≤55 anos de idade foram realizadas pela mesma dupla bolsa-formados cerebrovascular / neurocirurgião endovascular que desenvolveu essa técnica (EMD ) (Tabela 1). Essa faixa etária foi escolhida como ensaios anteriores d...

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

Craniotomia pterional tamanho de um polegar minimamente invasiva para clipagem de aneurisma tem proporcionado nossos pacientes com menor tempo de internação a um custo menor em comparação com a média nacional.

Minimamente Invasiva Thumb porte pterional craniotomia para pinça de aperto cirúrgica de Unruptured Anterior Aneurismas de circulação

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 visualizações.  Crouse Neuroscience Institute.  Craniotomia pterional tamanho de um polegar minimamente invasiva para clipagem de aneurisma tem proporcionado nossos pacientes com menor tempo de internação a um custo menor em comparação com a média nacional. 

Vídeo: 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.

Descompressão microvascular: Salient Princípios cirúrgicos e Nuances Técnica

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

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.

Permanente oclusão vascular cerebral<em&gt; Via</em&gt; Dupla ligadura e transecção

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.

Microcirúrgica Obliteration Clipe de Aneurisma Cerebral Médio Usando avaliação intra-operatória de fluxo

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.

Lateral Crônica Cranial Janela Preparação Ativa<em&gt; In Vivo</em&gt; Observação Após Distal Middle Cerebral Oclusão da Artéria em Ratos

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 ...

Neurociência

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.

Tratamento cirúrgico aberto de malformações arteriovenosas cerebrais e abrangente Endovascular

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.

Abordagem cirúrgica para oclusão da artéria cerebral média e reperfusão induzida por acidente vascular cerebral em ratos

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.

Oclusão de artéria Cerebral média, permitindo a reperfusão através de reparação de artéria carótida comum em ratos

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.

Criação de dois aneurismas saculares digeridos por elastase com hemodinâmicas diferentes em um coelho

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.

Otimização do Método de Oclusão da Artéria Cerebral Média Longa para Reperfusão 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 porte pterional craniotomia para pinça de aperto cirúrgica de Unruptured Anterior Aneurismas de circulação

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