RU2757345C1 - Method for contralateral endoscopic clipping of ophthalmic aneurysms of the internal carotid artery through a burr-hole access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurosurgery, and can be used for contralateral endoscopic clipping of ophthalmic aneurysms of the internal carotid artery. Burr-hole access is executed, including execution of a skin incision along the eyebrow line or along the natural crease of the upper eyelid, dissection of soft tissues, skeletisation of the underlying bone from the key point to the supraorbital incision, establishment of a hole in the key point, execution of supraorbital burr-hole craniotomy of 1.5 × 2 cm or orbitofrontal burr-hole craniotomy of 1.5 × 2 cm using a craniotome, opening of the dura mater with the size of the opening not exceeding 1.5 cm. The basal tanks are therein accessed subfrontally. After visualisation of the aneurysm, a 0° or 30° endoscope is inserted into the formed trepanation window. The endoscope is fixed on a pneumatic holder. The aneurysm is clipped with a vascular clip under endoscopic control. After the aneurysm is clipped, the endoscope is removed.

EFFECT: method provides leveling of the disadvantages associated with mini-accesses in the form of limited lighting and freedom in operation using micro-tools, eliminates ischemic damage to the visual apparatus and pituitary gland, reduces the risk of complications due to the use of endoscopic control and limited dissection, as well as focused opening of the basal cisterns and formation of a route to the contralaterally located aneurysm.

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Description

The invention relates to medicine, namely to neurosurgery.

In recent decades, there has been an active development of minimally invasive interventions. The results of using the keyhole concept in patients with aneurysms have shown that mini-approaches can be an alternative to traditional, extended craniotomies, through early patient recovery, excellent cosmetic and functional outcomes while minimizing surgical trauma with proper patient selection.

Surgical treatment of aneurysms of the ophthalmic segment of the internal carotid artery requires significant experience of a neurosurgeon and impeccable knowledge of the anatomy of the paraclinoid region. In modern conditions, an important stage in a successful result is the individualization of access with the planning of a microsurgical corridor. It is well known that ophthalmic aneurysms are often bilateral, which prompts surgeons to strive to turn off all aneurysms from the bloodstream using a unilateral approach. There is no doubt that contralateral clipping should be performed only with absolute indications: an aneurysm without rupture of small size (in order to minimize the volume of dissection), located on the superior or medial wall of the internal carotid artery, with mandatory visualization of the ophthalmic artery preoperatively on CT angiography and intraoperatively [Steven L. Giannotta. Ophthalmic Segment Aneurysm Surgery. Neurosurgery, Vol. 50, No. 3, March 2002].

Szeifert G. Bilateral supraorbital keyhole approach for multipleaneurysmsvi asuperciliary skin incisions. Surg Neurol. 2002; 57(5):314-323]; [Edner G (1991) One-session operation via bilateral craniotomies for multiple aneurysms after subarachnoid haemorrhage. Br J Neurosurg 5:55-60].A known method of treating cerebral aneurysms in the case of mirror aneurysms of the ICA, using bilateral access, both keyhole and traditional. Potential disadvantages of traditional bilateral craniotomies are usually associated with the large size of the trepanation window and significant concomitant trauma, which, in turn, can increase the risk of developing pyoinflammatory complications and the formation of epidural hematomas, and lead to negative functional and cosmetic effects. Accordingly, the risk of developing access-associated complications doubles [

Szeifert G. Bilateral supraorbital keyhole approach for multipleaneurysmsvi asuperciliary skin incisions. Surg Neurol. 2002; 57 (5): 314-323]; [Edner G (1991) One-session operation via bilateral craniotomies for multiple aneurysms after subarachnoid haemorrhage. Br J Neurosurg 5: 55-60].

As the closest analogue, the method of surgical treatment of ophthalmic aneurysms of the internal carotid artery (ICA) using the contralateral traditional approach, both for single and multiple aneurysms, was chosen. In this type of access, the skin is incised along the hairline, followed by dissection of soft tissues, skeletonization of the underlying bone. With the help of a high-speed bur and a craniotomy, a traditional 6 × 8 cm craniotomy (classic pterional approach) with resection of a part of the wing of the main bone is performed. Subsequently, the dura mater (5 × 5 cm) is widely opened in an arc-like manner and the transition to the main stage of the operation is carried out. The nuances of the main stage, in addition to the arachnoid dissection of the ipsilateral internal carotid artery, are the visualization of the contralateral optic nerve, internal carotid artery and aneurysm. After performing the above-mentioned manipulations, the neck of the aneurysm is selected and the trajectory of the vascular clip application is modeled. Upon completion of the main stage of the operation, the dura mater is sutured tightly, the bone is set in place, fixed with a titanium fixator, and soft tissues are sutured in layers. [Yasargil MG, Gasser JC, Hodosh RM, Rankin TV. Carotid-ophthalmic aneurysms: direct microsurgical approach. SurgNeurol. 1977 Sep; 8 (3): 155-65]; [Krylov V.V., Gelfenbein M.S. Use of the contralateral pterional approach in the surgery of cerebral aneurysms. The journal "Questions of neurosurgery" named after N.N. Burdenko. 1998; 4: 9-17]; [Krylov V.V., Tkachev V.V., Dobrovolsky G.F. Contralateral surgery of cerebral aneurysms. Moscow, medicine; 2002].

However, certain difficulties when using the contralateral traditional approach can arise due to the limited space for action and difficulties with proximal control, which is largely associated with insufficient visualization. Clipping can also be difficult due to the peculiarities of the location of the ophthalmic aneurysm in relation to the optic nerves and the ophthalmic artery; rough traction of the frontal lobes to increase visualization can lead to significant damage to the brain substance with the development of persistent neurological disorders. In addition to intraoperative nuances, there is also a considerable risk of developing access-associated complications, in the form of atrophy of the temporal muscle, facial asymmetry, risk of temporomandibular joint dysfunction, pain and numbness in the orofacial region, pain when chewing, discomfort when wearing glasses, damage to the frontal branch of the facial and supraorbital nerves, alopecia in the area of the postoperative scar. It is important that in most cases, with traditional approaches, structures are revealed that are not associated with the immediate goal of surgical intervention [De Andrade Junior FC, de Andrade FC, de Araujo Filho CM, Carcagnolo Filho J. Dysfunction of the temporalis muscle after pterional craniotomy for intracranial aneurysms :: prospective and randomized comparative study of one flap versus two flaps dieresis. Arq Neuropsiquiatr - 1998 - Vol. 56 - P. 200-205].

In this regard, the staff of the Department of Neurosurgery of the RMANPO proposed a method for endoscopic contralateral clipping of ophthalmic aneurysms of the internal carotid artery using burr-hole access.

The objectives of this invention are: improving the results of treatment of patients with ophthalmic aneurysms of the internal carotid artery using burr-hole-approaches under conditions of constant endoscopic control; reducing the risk of complications associated with excessive traction of the brain and wide opening of the dura mater; minimization of resection of bone structures by performing a unilateral contralateral approach, avoiding bilateral trepanations.

The task is solved in the following way. Before surgery, all patients underwent a standard routine examination plan before surgery. The preparation of the patient in the operating room included fixation of the head in a Mayfield-type bracket, with the head turning in the opposite direction by 15 ° -30 °. The proposed incision site is infiltrated with an anesthetic with the addition of a vasoconstrictor. An antiseptic eye gel is applied under the conjunctiva. Treatment of the operating field is performed with an aqueous solution of chlorhexidine 0.05%. The skin incision is performed along the eyebrow line (or along the natural crease of the upper eyelid, depending on the planned access), up to the line corresponding to the projection of the supraorbital notch. At the same time, the eyebrow is not shaved (in the case of trans-brow access). Subsequently, soft tissues are dissected, the underlying bone is skeletonized from the “key point” to the supraorbital notch. Then, using a high-speed bur, a hole is placed at the key point, with the help of a craniotome, a supraorbital burr-hole craniotomy 1.5 × 2 cm is performed, or a mini-orbital-frontal burr-hole craniotomy 1.5 × 2 cm. opening the dura mater does not exceed 1.5 cm. Access to the basal cisterns is performed subfrontally, without the use of retractors (to minimize traction trauma to the brain). Arachnoid dissection involves a focused and planned route without wide opening of the cisternae of the skull base to the contralateral aneurysm of the ophthalmic segment of the internal carotid artery. After visualization of the aneurysm, a 0 ° or 30 ° endoscope is inserted into the formed trepanation window, depending on the configuration of the aneurysm and its relationship with the optic nerve, anterior tilted process and the ophthalmic artery. The endoscope is mounted on a pneumatic holder for rigid fixation of the optics. Under direct endoscopic control, without removing the endoscope during the application of the clip, the aneurysm is clipped with the vascular clip. After clipping, the endoscope is removed, the hemostatic material is placed in the surgical site. The dura mater is sutured tightly, the bone is put in place and fixed with titanium clamps and / or a metal plate. Soft tissues are sutured in layers, a continuous intradermal suture is applied.

After the operation, the patients were in the neuroresuscitation department, after which they were transferred to the department. There was a moderate edema of the periorbital region, the regression of which occurred 3-4 days after surgery. Infectious complications, postoperative subcutaneous hematomas and liquorrhea were not observed.

The proposed method for contralateral endoscopic clipping of ophthalmic aneurysms of the internal carotid artery allows to improve visualization and illumination of critical structures during clipping and to evaluate the formation hidden from direct microsurgical view. The peculiarities of the operation is that the disadvantages associated with mini-accesses in the form of limitation of illumination and freedom in working with microinstruments can be leveled when using endoscopic control during clipping, especially when using a 30 ° endoscope (Fig. 1, A). In addition to the above, constant endoscopic control allows you to avoid shifting the clip when it enters its branches of the ophthalmic artery and / or small perforating arteries, which will eliminate ischemic damage to the visual apparatus and pituitary gland. The use of this technique during clipping also makes it possible to visualize and control the neck of the aneurysm at 180 ° to assess the completeness of closure of the jaws of the clips, which is not available when viewed through a microscope (Fig. 1, B). Focused opening of the basal cisterns and the formation of a route to the contralateral aneurysm can reduce the risk and severity of cerebral symptoms, which may be associated with a wide arachnoid dissection. Limited dissection of brain structures also reduces the risk of complications such as hydrocephalus and hygroma formation, infectious complications and liquorrhea. Reducing the trauma of the operation determines its effectiveness and safety, as well as the early activation of patients and the shortening of the bed-day with a decrease in the cost of treating patients with cerebral aneurysms. The above technique of endoscopic clipping is critical for aneurysms of the ophthalmic segment of the internal carotid artery, because the proximity of bone structures, in particular the lesser wing of the main bone and the anterior inclined process, the location of the ophthalmic artery and its course dictate the need for full illumination and adequate visualization directly in the area of the formed aneurysm. In addition to the above, the use of burr-hole approaches reduces the time of the operation by means of a small craniotomy and the minimum time spent on closing the defect.

Example. Patient M., 46 years old, was admitted to the neurosurgical department with complaints of recurrent headache. From the anamnesis it is known that the headaches appeared a month before hospitalization. On an outpatient basis, she performed an MPT of the brain, where a saccular aneurysm of the left internal carotid artery from the area of the ophthalmic segment was revealed. Upon further examination, MSCT-angiography of the brain, the diagnosis was confirmed. She applied for surgical treatment - clipping of the aneurysm.

In the somatic status without features, in the neurological status, the presence of general cerebral symptoms is noted. BP 125/80, heart rate 72 / min. After a routine preoperative examination, the patient was admitted to the operating room. During the operation, combined endotracheal anesthesia was used. The patient's head is fixed in the Mayfield bracket and rotated to the left by 30 °. The proposed incision site was infiltrated with anesthetic. An antiseptic eye gel was applied under the conjunctiva. The surgical field was treated with an aqueous solution of chlorhexidine 0.05%. The skin incision was performed along the right eyebrow line to the vertical line corresponding to the projection of the supraorbital notch. Subsequently, soft tissue dissection was performed, bleeding from small vessels of soft tissues during dissection was stopped by low-current bipolar coagulation. The underlying bone was skeletonized from the “key point” to the supraorbital notch. Then, using a high-speed bur, a hole was placed at the key point, a burr-hole craniotomy 1.5 × 2 cm was performed using a craniotome.The dura mater was opened with an arcuate base to the orbit (the opening width did not exceed 1.5 cm) and sutured to soft tissues. After relaxation of the brain, a focused arachnoid dissection of the psilateral carotid cistern was performed, followed by the chiasmal and contralateral carotid cisterns. In the area of the ophthalmic segment of the left internal carotid artery, a saccular aneurysm with dimensions of about 4 × 4 mm, the dome of which is directed upward, was visualized. Dissection of the neck and dome of the aneurysm was performed contralaterally. A 30 ° endoscope was inserted slightly posterior to the aneurysm to assess the neck width and its relationship with the ophthalmic artery and anterior tilted process. The endoscope is rigidly fixed with a pneumatic installation. Directly under endoscopic control, clipping of the aneurysm neck was performed, the ocular artery and the contralateral optic nerve were intact. The endoscope was removed, and the clip did not need to be repositioned. Control of hemostasis under microscopic magnification. The dura mater is sutured tightly. The bone flap is in place, fixed with two titanium clamps. Layer-by-layer wound closure. A continuous intradermal suture was applied. Aseptic dressing.

The postoperative period was uneventful, without complications. After the operation, the patient spent 24 hours in the intensive care unit of a neurological profile, the next day she was transferred to the department, and was activated on the day of transfer. No complications were observed. Vision is saved. There was a slight edema of the periorbital region, which completely regressed on the 3rd day after the operation. Discharged without complications on the 3rd day after surgery.

The results of the operation and intraoperative photos are presented in Fig. 2 and FIG. 3.

Description of drawings

FIG. 1 - CT angiography of the brain. Saccular aneurysm in the ophthalmic segment of the left internal carotid artery. A. Scheme of illumination of the clipping area using a 30 ° endoscope, visualization of both the medial and lateral sections of the cervix is available, it is possible to assess its relationship with the anterior inclined process. B. Illumination of the clipping area using a microscope. The lateral edge of the aneurysm is inaccessible to the view.

FIG. 2 - Intraoperative photos, endoscopic clipping of the aneurysm of the ophthalmic segment of the left internal carotid artery. A. An endoscope is installed, fixed by a pneumatic system. B. Endoscopic picture before applying a vascular clip. B. The clip is placed on the neck of the aneurysm.

FIG. 3 - CT angiography of the brain after surgery with 3D reconstruction before (A) and after (B) endoscopic clipping of the aneurysm of the ophthalmic segment of the left internal carotid artery (arrow), (C) CT of the skull bones with 3D reconstruction, showing the small size of trepanation.

Claims (1)

A method of contralateral endoscopic clipping of ophthalmic aneurysms of the internal carotid artery through a burr-hole approach, including performing a skin incision, dissection of soft tissues, skeletonization of the underlying bone using a high-speed bur, performing a craniotomy, accessing the basal cisterns subfrontally, arachnoid dissection along a focused and planned route a contralaterally located aneurysm of the ophthalmic segment of the internal carotid artery, characterized in that a burr-hole access is performed, including performing a skin incision along the eyebrow line or along the natural fold of the upper eyelid, dissection of soft tissues, skeletonization of the underlying bone from the key point to the supraorbital notch, placing a hole at the key point, performing a craniotomy of a supraorbital burr-hole craniotomy 1.5 × 2 cm, or an orbital-frontal burr-hole craniotomy 1.5 × 2 cm, opening the dura mater, with an opening size not exceeding 1.5 cm; at the same time, access to the basal cisterns is carried out subfrontally, after visualization of the aneurysm, an endoscope of 0 ° or 30 ° endoscope is introduced into the formed trepanation window, the endoscope is fixed on a pneumatic holder, the aneurysm is clipped with a vascular clip under endoscopic control; after clipping the aneurysm, the endoscope is removed.

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