DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Ruptured anterior communicating artery aneurysm.
POSTOPERATIVE DIAGNOSIS: Ruptured anterior communicating artery aneurysm.
PROCEDURE PERFORMED: Right pterional craniotomy for microscopic clipping of anterior communicating artery aneurysm.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal intubation.
TUBES AND DRAINS: A 7 mm flat subgaleal JP drain.
ESTIMATED BLOOD LOSS: 2000 mL.
COMPLICATIONS: Intraoperative aneurysm rupture.
CONSENT: The risks and benefits of the procedure were discussed at length to the patient and his wife, both of whom understand and agree to proceed.
DESCRIPTION OF OPERATION: The patient was brought into the operating room where he was induced under general anesthesia and intubated. He was placed in the supine position with the head turned slightly to the left and fixed with the Mayfield crown of thorns. Care was taken to ensure that all pressure points were carefully padded and that the limbs were positioned comfortably. A small strip of hair on the right side of his head was shaved and a curvilinear incision was marked on the scalp. This was extended down the forehead in the midline slightly due to the high hairline. The entire site was then prepped and draped in the usual sterile fashion. The indwelling right common femoral artery angiogram sheath was also prepped and draped sterilely.
The skin of the scalp was incised to full thickness with a #10 blade, and hemostasis was maintained with Raney clips. The scalp was reflected inferiorly through the fascia until the temporalis muscle was exposed. The temporalis was then cut, leaving a cuff on the bone and the muscle and scalp reflected inferiorly. They were reflected over a rolled 4 x 4 sponge and held in place with fishhooks. A bur hole was then placed in the frontal keyhole position and over the temporal bone. The underlying dura was stripped free of the inner table with blunt dissection. Care was taken down to frontal bur hole to palpate the floor of the anterior fossa to mark the trajectory of the craniotomy.
Using B1 drill bit with the footplate, the craniotomy was turned between both bur holes. The bone over the sphenoid wing was thinned with the B1 drill bit, and the craniotomy was cracked at that point and removed as a single piece. Using a Leksell rongeur and the B1 drill bit, the sphenoid wing was drilled down to a flat trajectory along with the inner table of the frontal bone, and bone wax was applied for hemostasis. The dura was then opened in semilunar fashion and reflected inferiorly with a 4-0 Vicryl suture. The Budde halo was then attached to the Mayfield crown of thorns with two retractors, and the microscope was brought into position.
Under microscopic guidance, the frontal lobe was elevated with the retractors over Telfa strips. The arachnoid was dissected away from the optic nerve to release CSF. The carotid artery was then dissected free of the optic nerve and away from the arachnoid as well to allow proximal control, and then extended arachnoid opening across the midline until the opposite optic nerve could be visualized and then extended back posteriorly until the A1 segment of the right anterior cerebral artery was visualized. At this point, we could identify the recurrent artery of Heubner and therefore the presumed junction of the A1 and A2 segments. We dissected across the midline until the contralateral A1 segment of the anterior cerebral artery on the left was visualized. These were then followed medially until we identified the interhemispheric fissure.
Using microscopic scissors and nerve hook retractor, the interhemispheric fissure of arachnoid was elevated and cut to expose the A2 segment and the anterior communicating artery itself. A dark red blister on the genu of the right A1 and A2 junction was visualized, but this did not follow the trajectory as expected for the aneurysm on the angiogram. For that reason, additional arachnoid dissection was undertaken around this blister and behind it until the more superiorly oriented aneurysm was visualized. We then took time to dissect the plane between the aneurysm neck and the A2 arteries on each side. We first attempted to free the aneurysm with a straight 5 mm permanent clip but found that this would not fit through the dissected space on the aneurysm neck and tended to roll the anterior communicating artery backwards. Therefore, we performed some additional dissection in preparation for placing a side-angled clip.
During dissection, however, the aneurysm ruptured. We placed the permanent side-angled clip across the aneurysm neck with rapid control of the bleeding, but there was still some arterial bleeding from the posterior portion of the aneurysm. To allow better clip placement, temporary aneurysm clips were then placed in both A1 segments of each anterior cerebral artery. The aneurysm clip was then removed and then reapplied more inferiorly across the base of the neck of the aneurysm. Once this was placed, we found no additional arterial bleeding. The temporary aneurysm clips were removed and the aneurysm remained collapsed with no bleeding. We chose then to treat the additional blister aneurysm at the right A1 and A2 junction with a straight 3 mm mini clip. After each of these clips were in place and there was no bleeding ongoing, the A1 and A2 segments on each side were checked by micro Doppler. Good flow was identified in each of the four vessels with no flow signal heard in the aneurysm.
At this point, we placed two small pieces of thrombin-soaked Gelfoam to ensure good hemostasis. A papaverine-soaked Gelfoam was then laid down across the A1 segment. The microscope was then removed along with the retractors and the Telfa strips. The Budde halo was detached. The dura was overlaid with a moist piece of Telfa, and the scalp was temporarily closed with a 2-0 Vicryl suture. An intraoperative angiogram was then performed. As the angiogram demonstrated patency of both A2 segments and occlusion of the aneurysm, we chose to finish with the closure.
The scalp was then reflected back over the 4 x 4 sponges with fishhooks. The Telfa was removed, and the brain was irrigated with lactated Ringer’s to remove all blood products. After ensuring good hemostasis, the dura was closed with 4-0 Vicryl sutures. It was overlaid with a Bicol sponge. The bone flap was then fixed back in place with Synthes craniofacial plates and screws. The temporalis muscle was then sewn back to the fascia cuff on the bone with 2-0 Vicryl sutures. A 7 mm flat JP drain was passed through a separate stab incision and cut to length in the subgaleal space. The galea was then closed with 2-0 Vicryl sutures in the simple inverted interrupted fashion, and the skin closed with skin staples. The wound was dressed with Telfa, dressing sponge, and loose Kerlix head wrap after removing the Mayfield crown of thorns. The patient was awakened from anesthesia and extubated without difficulty. The patient was then taken to the postanesthesia care unit in stable condition. There were no additional complications.
