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| Name | Aneurysmal clipping with Anterior Clinoidectomy,Extradural Temporopolar app |
| Video Uploader | Video From Dr.T's Neurovascular channel |
| Upload Date | This Video Uploaded At 24-06-2024 05:34:49 |
| Video Discription | 破裂IC-PC ANにおけるextradural temporopolar approach 症例 ○歳，女性，突然の頭痛，意識障害にて発症した右内頚動脈－後交通動脈 分岐部（IC-PC）の破裂脳動脈瘤． 術前診断 CTAにて，右IC-PC部に，最大径4.8mmの不正形の嚢状動脈瘤を認める．WFNS grade5, Hunt & Kosnik grade4, Fisher group3. 手術手技 緊急開頭クリッピング術を施行．前頭側頭開頭後，distal transsylvian approachを進めていくとanterior temporal artery(ATA)とsuperficial sylvian vein (SSV)がansaを形成していた．この状態では，SSVの可動性が制限されておりanterior temporal approachの術野展開が困難と判断し，extradural tempolopolar approachへと切り替えることとした．Dura propriaをpeel offし，前床突起を削除後，削除した前床突起後のspaceに向かって硬膜切開を追加(clinoidal approach)する．この操作にて，先ほどのATAとansaを形成していたSSVを硬膜ごと，外側方に牽引することが可能となり，anterior temporal approachと同等の術野展開を得ることができた．その後は，neck clipping完遂し，積極的脳槽血腫洗浄(aggressive cisternal clot removal: ACCR)を施行した．可及的に6-0 PRONOVAⓇで硬膜を縫合し，青ベリゼルフォームで硬膜内外からin & out layで充填し硬膜内操作を終了した． 術後CTAで，clippingに問題ないことを確認した．経過中，症候性脳血管攣縮は認めず，mRS1で独歩退院となった． この症例は，dura propriaの挙上，前床突起削除の手技は，傍鞍部動脈瘤のみならず，内頚動脈C1部動脈瘤においても，頭蓋内でのworking spaceを確保する目的で，有用である．また，anterior temporal approachの際，SSVの走行により術野展開が制限されている場合，extradural temporopolar approachへとswitchする際に必須の手技である． The application of the extradural temporopolar approach in a ruptured IC-PC aneurysm Case: A X-year-old female presenting with sudden headache and impaired consciousness due to a ruptured intracranial aneurysm at the right internal carotid artery-posterior communicating artery (IC-PC) bifurcation. Preoperative Diagnosis: CTA revealed an irregular saccular aneurysm with a maximum diameter of 4.8 mm at the right IC-PC bifurcation. The patient was classified as WFNS grade 5, Hunt & Kosnik grade 4, Fisher group 3. Surgical Procedure An emergency craniotomy and clipping procedure were performed. After a frontotemporal craniotomy and progression with the distal transsylvian approach, it was observed that the anterior temporal artery (ATA) and the superficial sylvian vein (SSV) formed an ansa. In this situation, the mobility of the SSV was limited, making the surgical field expansion using the anterior temporal approach difficult. Therefore, the decision was made to switch to an extradural temporopolar approach. The dura propria was peeled off, the anterior clinoid process was removed, and an additional dural incision (clinoidal approach) was made towards the space behind the removed anterior clinoid process. This maneuver allowed the previously mentioned ATA and the SSV forming the ansa to be retracted laterally along with the dura, thereby achieving a surgical field expansion equivalent to the anterior temporal approach. Subsequently, neck clipping was completed, and aggressive cisternal clot removal (ACCR) was performed. The dura was sutured as much as possible with 6-0 PRONOVA®, and the intra- and extra-dural spaces were filled in and out with Blue Bellizel Form, concluding the intradural procedure. Postoperative CTA confirmed that there were no issues with the clipping. During the follow-up, no symptomatic cerebral vasospasm was observed, and the patient was discharged independently with an mRS score of 1. In this case, the techniques of elevating the dura propria and removing the anterior clinoid process proved useful not only for parasellar aneurysms but also for securing the intracranial working space in internal carotid artery C1 aneurysms. Additionally, when the surgical field expansion is restricted by the course of the SSV during the anterior temporal approach, switching to the extradural temporopolar approach is an essential technique. |
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