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| Name | Subtemporal Approach for AICA Aneurysm Clipping |
| Video Uploader | Video From NEUROSURGERY Journal |
| Upload Date | This Video Uploaded At 15-05-2014 13:29:43 |
| Video Discription | Proximal anterior inferior cerebellar artery (AICA) aneurysms are generally managed endovascularly. However, surgery is a viable option when endovascular treatment is unfavorable. AICA aneurysms that are small, unruptured, at the artery's origin, and laterally directed are ideal for the Kawase approach, providing a more direct view than a retrosigmoid exposure. The length of the retrosigmoid corridor is similar to Kawase's corridor, but the perspective is tangential, the dome is reached first, and contralateral anatomy is difficult to visualize. Alternative approaches are inadequate; the far lateral approach does not reach high enough to expose AICA and the pterional transsylvian approach does not reach low enough without significant transcavernous dissection. This step-by-step 3-D-HD video demonstration starts extradurally, transitions intradurally, returns extradurally with tentoriotomy, then finishes intradurally again. A pterional craniotomy, exposure of the middle fossa floor, and extradural medial petrosectomy (medial to petrous ICA) are the first steps. The greater superficial petrosal nerve (GSPN) is sectioned to avoid traction on the geniculate ganglion. The cochlea forms the posterolateral limit of the petrosectomy. Intradurally, a subtemporal approach exposes the ambient cistern and trochlear nerve (CN4). CN4 enters its tentorial canal anteriorly as it approaches the cavernous sinus and can be freed from the tentorium posteriorly. The tentorium is cut from medial to lateral to the level of the superior petrosal sinus, which is ligated and plugged with fibrin glue. The extradural compartment is communicated with the intradural exposure with a second incision in the tentorium, bringing the trigeminal nerve (CN5) into view. Dissection returns intradurally with an incision in the dura of the posterior petrous face. Infratentorial intradural dissection proceeds lateral to both Meckel's cave and CN5 to expose the basilar artery and both the AICA artery origin and aneurysm. At this depth, the abducens nerve is visualized entering Dorello's canal. Dissection and clipping are performed through a small window in the medial petrous bone. Indocyanine green confirms clipping and vessel patency. A medial petrosectomy with limited opening of just the posterior petrous dura at the level of the pons would have been more minimalistic, but as the video demonstrates, an already narrow window would have been even more constricted. The additional exposure gained by dissecting intradurally and dividing the tentorium allows medial mobilization of CN5 in Meckel's cave for additional exposure and optimization of the trajectory to visualize and clip the AICA aneurysm. |
| Category | Science & Technology |
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