Surgical Anatomy of Endoscope-Assisted Approaches to Common Aneurysm Sites

2013 ◽  
Vol 10 (1) ◽  
pp. 121-144 ◽  
Author(s):  
Maria Peris-Celda ◽  
Leila Da Roz ◽  
Alejandro Monroy-Sosa ◽  
Takashi Morishita ◽  
Albert L. Rhoton
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Optic Tract ◽  
Small Diameter ◽  
Vascular Anatomy ◽  
Surgical Anatomy ◽  
Microsurgical Anatomy ◽  
Endoscopy Training ◽  
Endoscopic View ◽  
Endoscopic Assistance

Abstract BACKGROUND: The endoscope is being introduced as an adjuvant to improve visualization of certain areas in open cranial surgery. OBJECTIVE: To describe the endoscopic anatomy of common aneurysm sites and to compare it with the microsurgical anatomy. METHODS: Pterional, anterior interhemispheric, and subtemporal approaches to the most common aneurysm sites were examined in cadaveric heads under the surgical microscope and with the endoscope. RESULTS: The endoscopic view, particularly with the angled endoscopes, provides a significant improvement compared with the microscopic view, especially for poorly visualized sites such as the medial aspect of the supraclinoid carotid artery and its branches, the area below the anterior perforated substance and optic tract, and the carotid and basilar bifurcations. The endoscope aided in the early visualization of perforating branches at each aneurysm site except the middle cerebral artery. Small-diameter optics (2.7 mm) provided greater space for dissection and less potential for tissue damage in narrow places, whereas the larger 4-mm diameter optics provided better visualization and less panoramic distortion. The positioning of the endoscope for each aneurysm site is reviewed. CONCLUSION: The endoscope provides views that complement or improve the microscopic view at each aneurysm site except the middle cerebral artery. Endoscopy training and a thorough knowledge of endoscopic vascular anatomy are essential to safely introduce endoscopic assistance in vascular surgery.

A 1-Donor 2-Recipient Superficial Temporal Artery-Middle Cerebral Artery Bypass for Moyamoya Syndrome: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Nickalus R Khan ◽  
Jacques J Morcos
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Bypass ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Surgical Anatomy ◽  
Large Area ◽  
Ischemic Disease ◽  
Near Occlusion ◽  
Direct Bypass

Abstract We present the case of a 34-yr-old male who suffered repeated ischemic events resulting in right-sided weakness. He was found to have left M1 segment near occlusion on angiography with a large area of uncompensated hypoperfusion. The patient underwent a direct superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Direct bypass in the acute setting of ischemia has been previously described.1-5 Moyamoya ischemic disease can be treated with either direct or indirect surgical revascularization. There have been several techniques developed for direct bypasses in moyamoya ischemic disease. These include the standard 1-donor 1-recipient (1D1R) end-to-side (ES) bypass, the “double-barrel” 2-donor 2-recipient (2D2R) ES bypass, and the more recently developed 1-donor 2-recipient (1D2R)6,7 utilizing both an ES and a side-to-side (SS) bypass with a 1-donor vessel. The case presentation, surgical anatomy, decision-making, operative nuances, and postoperative course and outcome are reviewed. The patient gave verbal consent for participating in the procedure and surgical video.

Microsurgical Anatomy of the Supracerebellar Transtentorial Approach to the Posterior Mediobasal Temporal Region: Technical Considerations With a Case Illustration

2008 ◽  
Vol 62 (suppl_1) ◽  
pp. ONS1-ONS8 ◽  
Author(s):  
Roham Moftakhar ◽  
Yusuf Izci ◽  
Mustafa K. Basşkaya
Keyword(s):  
Temporal Lobe ◽  
Vascular Anatomy ◽  
Surgical Anatomy ◽  
Parahippocampal Gyrus ◽  
Temporal Region ◽  
Microsurgical Anatomy ◽  
Posterior Portion ◽  
Surgical Access ◽  
Formidable Challenge ◽  
Left Posterior

Abstract Objective: Surgical access to the posterior portion of the mediobasal temporal lobe presents a formidable challenge to neurosurgeons, and much controversy still exists regarding the selection of the surgical approach to this region. The supracerebellar transtentorial (SCTT) approach to the posterior mediobasal temporal region can be used as an alternative to the subtemporal or transtemporal approaches. The aim of this study was to demonstrate the surgical anatomy of the SCTT approach and review the gyral, sulcal, and vascular anatomy of the posterior mediobasal temporal lobe. The use of this approach in the resection of a ganglioglioma located in the left posterior parahippocam-pal gyrus is illustrated. Methods: The SCTT approach to the posterior parahippocampal gyrus was performed on three silicone-injected cadaveric heads. The gyral, sulcal, and arterial anatomy of the posterior mediobasal temporal lobe was studied in six formalin-fixed injected hemispheres. Results: The SCTT approach provided a direct path to the posterior mediobasal temporal lobe and exposed the posterior parahippocampal gyrus as well as the adjacent gyri in all of the cadaveric specimens. Through this approach, gross total resection of the ganglioglioma was possible in our patient. Conclusion: The SCTT approach provided a viable surgical route to the posterior mediobasal temporal lobe in the cadaveric studies. This approach provides an advantage over the subtemporal and transtemporal routes in that there is less temporal lobe retraction.

scholarly journals Microsurgical anatomy of the middle cerebral artery

2005 ◽  
Vol 53 (2) ◽  
pp. 186 ◽  
Author(s):  
SBalaji Pai ◽  
RG Varma ◽  
RN Kulkarni
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Microsurgical Anatomy

Microsurgical Clipping and Bypass for Fusiform Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Nickalus R Khan ◽  
Stephanie H Chen ◽  
Jacques J Morcos
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Superficial Temporal Artery ◽  
Artery Aneurysm ◽  
Patient Discharge ◽  
Temporal Artery ◽  
Surgical Anatomy ◽  
Microsurgical Treatment ◽  
Microsurgical Clipping

Abstract Fusiform middle cerebral artery (MCA) aneurysms that require treatment can often necessitate complex endovascular or microsurgical treatment. We present a case of a 25-yr-old female with an incidentally discovered left 14-mm fusiform MCA aneurysm incorporating the frontal MCA trunk origin in its dome. The location and anatomy were not favorable for endovascular treatment with flow diversion.  The patient was offered continued observation or microsurgical treatment. Direct clipping of this aneurysm was not possible. After a thorough discussion of the risks, benefits, indications, and natural history of the lesion, the patient desired to have the aneurysm treated given her young age, location, size of the aneurysm, and the significant clinical experience of the treating team in bypass surgery.  The patient underwent superficial temporal artery to frontal M2 (STA-FM2) direct bypass for flow replacement followed by microsurgical trapping and clip ligation. The patient was maintained on antiplatelet therapy preoperatively and postoperatively. The patient had a transient aphasia and mild right upper extremity weakness (4/5) in the immediate postoperative period, which fully recovered by the time of patient discharge. The case presentation, surgical anatomy, technique, and postoperative course and outcome are reviewed. The different strategies for bypass and clip ligation are reviewed with particular focus on the anatomic constraints for each bypass configuration. The outcomes of bypass surgery for MCA aneurysms are reviewed.1-7 The patient gave verbal consent for participating in the procedure, surgical video, and publication of their image.

Image Guidance for Transcranial Doppler Ultrasonography

2011 ◽  
Vol 68 (suppl_2) ◽  
pp. ons257-ons266 ◽  
Author(s):  
Sven R. Kantelhardt ◽  
Christian Greke ◽  
Naureen Keric ◽  
Fritz Vollmer ◽  
Ingmar Thiemann ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Transcranial Doppler ◽  
Image Guidance ◽  
Flow Analysis ◽  
Vascular Anatomy ◽  
Diagnostic Procedures ◽  
Computed Tomographic Angiography ◽  
Guidance System ◽  
Image Guided

Abstract Background: Transcranial Doppler (TCD) ultrasonography is an important tool for noninvasive detection and monitoring of vasospasm and other pathological conditions of the intracranial vessels. Objective: To demonstrate that image-guided TCD allows rapid identification and blood-flow analysis of specific sections of the vascular anatomy and provides excellent orientation, also allowing diagnostic procedures on pathological vascular structures. Methods: Three patients who underwent computed tomographic angiography scanning for reasons not related to this study were examined by neuronavigated image-guided TCD. The Doppler probe was fitted with reflective markers and tracked by a commercially available Kolibri image guidance system. Results: Image-guided TCD allowed identification of all major intracranial vessels. Unilateral acquisition of reliable Doppler signals for the internal carotid artery, carotid T, middle cerebral artery, middle cerebral artery bifurcation, and anterior cerebral artery required 14 ± 6 minutes. Preregistration of these targets and detection by neuronavigation alone shortened examination times significantly to 8 ± 2 minutes. Registering the optimal examination trajectories on the neuronavigational device and applying navigational pilot software shortened times for repetitive examination further to 4 ± 1 minutes and ensured that the examination was done at the exact same spot under the same angle as in previous examinations. Conclusion: Image guidance can be applied easily and efficiently to TCD. It provides anatomic orientation and may help to standardize investigation protocols, define pathological vascular territories for repeat investigations, and thus reduce interinvestigator variations. Image guidance may also extend the use of TCD to situations of a pathological or variant vascular anatomy.

Microsurgical Anatomy of the Temporal Lobe: Part 2—Sylvian Fissure Region and Its Clinical Application

2009 ◽  
Vol 65 (suppl_6) ◽  
pp. ons1-ons36 ◽  
Author(s):  
Hung Tzu Wen ◽  
Albert L. Rhoton ◽  
Evandro de Oliveira ◽  
Luiz Henrique M. Castro ◽  
Eberval Gadelha Figueiredo ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Clinical Application ◽  
Cerebral Artery ◽  
Lateral Surface ◽  
Artery Aneurysm ◽  
Sylvian Fissure ◽  
Microsurgical Anatomy ◽  
Temporal Stem ◽  
Middle Cerebral Artery Aneurysms ◽  
Anatomic Information

Abstract Objective: We present observations of the anatomy of the sylvian fissure region and their clinical application in neuroimaging, microsurgery for middle cerebral artery aneurysms and insular lesions, frontobasal resections, and epilepsy surgery. Methods: Sixty adult cadaveric hemispheres and 12 adult cadaveric heads were studied after perfusion of the arteries and veins with colored latex. The anatomic information was applied in more than 200 microsurgeries in and around the sylvian fissure region in the past 15 years. Results: The sylvian fissure extends from the basal to the lateral surface of the brain and presents 2 compartments on each surface, 1 superficial (temporal stem and its ramii) and 1 deep (anterior and lateral operculoinsular compartments). The temporal operculum is in opposition to the frontal and parietal opercula (planum polare versus inferior frontal and precentral gyri, Heschl’s versus postcentral gyri, planum temporale versus supramarginal gyrus). The inferior frontal, precentral, and postcentral gyri cover the anterior, middle, and posterior thirds of the lateral surface of the insula, respectively. The pars triangularis covers the apex of the insula, located immediately distal to the genu of the middle cerebral artery. The clinical application of the anatomic information presented in this article is in angiography, middle cerebral artery aneurysm surgery, insular resection, frontobasal resection, and amygdalohippocampectomy, and hemispherotomy. Conclusion: The anatomic relationships of the sylvian fissure region can be helpful in preoperative planning and can serve as reliable intraoperative navigation landmarks in microsurgery involving that region.

Nuances of Middle Cerebral Artery Aneurysm Microsurgery

Neurosurgery ◽  
2001 ◽  
Vol 48 (2) ◽  
pp. 339-346 ◽  
Author(s):  
Douglas Chyatte ◽  
Rebecca Porterfield
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Aneurysm ◽  
Surgical Anatomy ◽  
Surgical Approaches ◽  
Common Source ◽  
Transsylvian Approach ◽  
Microsurgical Clipping ◽  
Technical Requirements ◽  
Middle Cerebral Artery Aneurysms

Abstract Middle cerebral artery aneurysms, a common source of subarachnoid hemorrhage, occur predominantly at the main bifurcation of the middle cerebral artery. Microsurgical clipping is the most effective treatment of these aneurysms because of their peripheral location, wide necks, and straightforward surgical anatomy. Despite the moderate technical requirements of this type of surgery, patients with ruptured aneurysms often have poor outcomes because of the high incidence of intracerebral hematomas. Although several different surgical approaches can be used, we favor a lateral-to-medial transsylvian approach for most aneurysms. This description of our surgical technique stresses minimizing retraction to avoid injury to the brain and preparing broad-based middle cerebral artery aneurysms for clipping. Management of outcomes when using these techniques also is presented.

Orthogonal Interlocking Tandem Clipping Technique for the Reconstruction of Complex Middle Cerebral Artery Aneurysms

2006 ◽  
Vol 59 (suppl_4) ◽  
pp. ONS-347-ONS-352 ◽  
Author(s):  
Richard E. Clatterbuck ◽  
Robert M. Galler ◽  
Rafael J. Tamargo ◽  
David J. Chalif
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Vascular Anatomy ◽  
Line Of Sight ◽  
Aneurysm Clip ◽  
Neurological Outcomes ◽  
Complex Aneurysms ◽  
Clinical Presentations ◽  
Clipping Technique ◽  
Middle Cerebral Artery Aneurysms

Abstract OBJECTIVE: Complex aneurysms arising at the middle cerebral artery (MCA) bifurcation frequently present a microsurgical challenge to effectively obliterate while maintaining patency of the distal MCA branches. These aneurysms are often multilobed, with their long axis aligned with the long axis of the M1 trunk, placing the dome of the aneurysm in the surgeons' line of sight, preventing an unobstructed view of the entire bifurcation and proximal M1 segment. MCA aneurysms often have a broad neck, splaying the bifurcation. An orthogonal interlocking tandem clipping technique, maximizing the use of fenestrated aneurysm clips, is presented as a means to completely obliterate the aneurysm and simultaneously “reconstruct” the MCA bifurcation. CLINICAL PRESENTATIONS AND INTERVENTION: Fifteen complex MCA aneurysms were treated using an interlocking tandem clipping technique. In its simplest application, the blades of the initial aneurysm clip are incorporated into the fenestration of the second clip. Obliteration of the residual aneurysm is achieved with the blades of the second, fenestrated clip. RESULTS: Satisfactory aneurysm obliteration and reconstruction of the MCA bifurcation was achieved in all cases using this technique, with excellent neurological outcomes. CONCLUSION: Morphologically complex multilobed MCA aneurysms can be effectively clipped with “reconstruction” of the normal vascular anatomy using a tandem interlocking clipping technique. A fenestrated clip is used to incorporate the blades of the initial clip, while obliterating the remainder of the aneurysm.

Sequential Coiling-Assisted Deployment of Flow Diverter for Treatment of Fusiform Middle Cerebral Artery Aneurysms

2017 ◽  
Vol 15 (2) ◽  
pp. E13-E18 ◽  
Author(s):  
Abdulrahman Y Alturki ◽  
Philip G R Schmalz ◽  
Christopher S Ogilvy ◽  
Ajith J Thomas
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Vascular Anatomy ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Anterior Circulation ◽  
Vertebrobasilar System ◽  
Middle Cerebral Artery Aneurysms ◽  
Vessel Reconstruction

Abstract BACKGROUND AND IMPORTANCE Fusiform intracranial aneurysms remain challenging lesions to treat. These aneurysms have historically required bypass procedures or clip remodeling constructs for cure. Recently, endovascular specialists have reported experience with flow diversion for complex fusiform aneurysms of the vertebrobasilar system, with mixed results. Vascular anatomy for anterior circulation fusiform aneurysms may make these lesions more amenable to flow diversion and embolization procedures; however, published experience with these techniques is lacking. In this report, we describe a sequential coiling-assisted deployment of flow diverter for the treatment of fusiform middle cerebral artery (MCA-M1) aneurysms in 2 cases, 1 presenting acutely with subarachnoid hemorrhage and another with progressive aneurysm enlargement. CLINICAL PRESENTATION Two patients, a 36-yr-old male presenting with subarachnoid hemorrhage and a 60-yr-old female presenting with aneurysm enlargement were treated for fusiform aneurysms of the M1 segment of the MCA using a sequential, partial deployment of coils and flow diverter through 2 microcatheters to facilitate mutual mechanical support for both coil and flow diverter (Pipeline Embolization Device; Medtronic Inc, Dublin, Ireland). Both patients achieved favorable outcomes and follow-up angiography demonstrated complete vessel reconstruction in both cases. CONCLUSION The treatment of complex, fusiform, large vessel aneurysms remains challenging. As experience with new endovascular technologies and techniques grows, these lesions may be treated safely with interventional methods. The technique of partial flow diverter deployment and stabilization with coils with sequential delivery of both devices using dual microcatheter was both safe and effective.

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