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Clipping of MCA aneurysms: how I do it
Philippe Bijlenga1, Vitor Mendes Pereira, Karl Schaller
1Service de Neurochirurgie, Département de Neurosciences Cliniques, Hôpitaux Universitaire de Genève, Faculté de médecine, Université de Genève, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland. philippe.bijlenga@hcuge.ch
Introduction:
Aneurysms located at the middle cerebral artery bifurcation remain a clear neurosurgical indication. We detail here the steps necessary to enable safe surgery for Sylvian fissure aneurysms.
Methods:
An angiogram with 3D reconstruction is obtained and reviewed intraoperatively, just prior to the skin incision. During the exposure, the cistern is kept open by small cottonoids, thereby avoiding brain retraction. Continuous monitoring of MEPs along with ICG microscopic angio-fluorescence allows for detection of vascular compromise. Intraoperative angiography with 3D reconstruction allows for immediate correction of less than satisfactory surgical outcome.
Conclusions:
Careful planning of surgical strategy followed by a minimally invasive technique (with continuous neuro-monitoring) ensures safe surgery. The availability of intra-operative radiological guidance allows for optimal management.
Insights
This study outlines a minimally invasive surgical technique for middle cerebral artery aneurysms. Continuous neuro-monitoring and intraoperative imaging ensure patient safety and optimal surgical outcomes.
Area of Science:
- Neurosurgery
- Vascular Neurology
Background:
- Middle cerebral artery (MCA) bifurcation aneurysms are a common neurosurgical indication.
- Safe surgical access to Sylvian fissure aneurysms requires specific techniques.
Purpose of the Study:
- To detail the steps for safe surgical management of Sylvian fissure aneurysms.
- To emphasize the importance of minimally invasive techniques and intraoperative guidance.
Main Methods:
- Preoperative and intraoperative 3D-reconstructed angiography for surgical planning and immediate assessment.
- Minimally invasive Sylvian fissure exposure using cottonoids to maintain cistern patency and avoid brain retraction.
- Continuous monitoring of motor evoked potentials (MEPs) and intraoperative indocyanine green (ICG) microscopic angio-fluorescence for vascular integrity.
Main Results:
- The described technique facilitates safe surgical access and aneurysm treatment.
- Continuous neuro-monitoring and ICG angio-fluorescence effectively detect vascular compromise.
- Intraoperative angiography allows for prompt correction of any suboptimal surgical results.
Conclusions:
- Careful surgical planning and a minimally invasive approach are crucial for safe aneurysm surgery.
- Continuous neuro-monitoring and intraoperative radiological guidance are essential for optimal patient management and outcomes.
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