Name: minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms
Uploaded: 2015-08-11T13:00:00.000+00:00
Duration: 11 min 58 s
Description: Watch this Scientific Journal Video about Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms at JoVE.com

The authors have no acknowledgments.

注:在执行此过程，获得所有必要的机构批准和患者同意。 1.手术技巧<ol><li>导致患者全身麻醉。 </li><li>将桡动脉血压监测。 </li><li>将病人在手术室表仰卧位。 </li><li>后头部被夹入使用标准技术用于一个翼点开颅梅菲尔德头保持器，与同侧面朝上放置磁头30°-45°朝天花板，除了在该头被放置在60°的前 - 交通动脉瘤要允许跨纵裂更好的可视化。 </li><li>定位颈部中线和翻译前方最大限度颈静脉引流，以防止脑水肿，然后扩展的头部来定位同侧颧骨处的最高点，这允许额叶松弛和埃尔evation从解剖过程中眶顶不使用拉钩的。 </li><li>夹头发，准备标准翼点入头皮切口;使用约一到发际线后面两英寸带。 </li><li>无菌预习皮肤并根据护理标准悬垂手术区。 </li><li>对于一个翼点入路从发际后面头皮的中线与平缓曲线向后和下方朝向耳珠延伸它结束约3mm前向耳屏，并在颧骨的上边缘的水平执行标准弯曲头皮切口。执行此切口向下上述颞线和肌肉筋膜在颞肌的电平的头骨。 </li><li>使用电灼对于头皮止血用的双极型器件。 </li><li>切开颞肌下使用该bovie刀单极电设备的头骨。 </li><li>养肌皮瓣保持连接到颞肌底面头皮现在。鱼钩用于外翻皮瓣后颞肌，从使用单极电和骨膜电梯的组合颅骨升高。 </li><li>使用梅岑鲍姆剪刀肌皮瓣的底面进行了股骨头缺血性平面逆筋膜切开，保持筋膜和subfacsial脂肪垫头皮，以免损伤面神经。 </li><li>固定颞肌向后下方，并揭露翼点入路区域与"明星"鱼钩。 </li><li>保持肌皮瓣湿润湿润纱布的所有组件。 </li><li>钻一个单一时间5毫米毛刺孔在计划的开颅有2mm切削毛刺的最靠后的方面，使得侧切削钻头的脚踏板可被插入到该孔，然后使用侧切割钻头用脚板除去拇指大小（约3×4厘​​米）肾形开颅CENTE周围的翼点入路前方的红色。 </li><li>使用1号潘菲尔德，分开的翼点的所有侧硬脑膜和有一个助理轻轻缩回硬脑膜远离正被钻出，以尽量减少穿透硬脑膜和造成皮层受伤的风险的骨表面。 </li><li>用钻头取出翼点入路:向前，直至眶顶的上级和横向方面光滑，上下扁平骨的外侧皮质表，没有进入轨道，以最大限度地暴露额下;内侧，直到钻眶上裂硬膜暴露并取出小块骨头会干扰曝光内侧使用一个钻头或手持Lempert骨切割设备。确保所有的软组织和骨的表面是优秀的止血已经获得避免鲜血淋漓进入硬膜内空间的大脑解剖和动脉瘤曝光时，使用electrocaurtery和骨蜡可以根据需要，在打开硬脑膜前。 </li><li>轻轻地提升硬脑膜并使用11号手术刀穿透硬脑膜，然后用剪刀硬膜创建与底座的翼点入路一个"C"形开口硬脑膜。对固定轨道的外骨皮质硬脑膜平，而无需多余的硬膜小叶那会近端外侧裂和额下区，否则不起眼的可视化。这可以通过使用4-0 Surgilons缝合钉硬脑膜到头皮进行。 </li></ol> 2.大脑放松<ol><li>给25-50 1g甘露糖醇的骨瓣清除的时间来放松大脑，如果麻醉同意，血压会容忍利尿。 注:这将允许时间发生利尿，并最终将放松大脑，帮助清扫过程中最大限度地提高重力依赖大脑回缩。 </li><li>保持呼气末二氧化碳分压30-35毫米汞柱之间实现小幅hypercapnea。注:这将放心地让大脑放松和马解剖过程中ximize重力相关的脑回缩。 </li><li>撤离脑脊液（CSF）由interoptic，颈光打开蛛网膜蓄水池，以促进大脑的放松，和颈内动脉动眼神经水箱和耐心吸CSF，直到所需的大脑放松已经实现。 注:这通常需要约1分钟;没有腰漏极与需要这种技术，它极大地打开了手术走廊。 </li></ol> 3.外侧裂解剖<ol><li>使手术中的显微镜与瓶口成使用无菌​​技术领域中。同时也带来手术的椅子臂支撑到现场无菌最大限度地双手灵巧和防止外科医生的胳膊和手部疲劳。 注:吹嘴应悬垂，使得外科医生可以移动显微镜用口，同时期待通过目镜件之前进行调整。 </li><li>进行清扫。 注:对于前交通动脉瘤，无外侧裂解剖是必需的，最小的（2-3毫米只有极端的情况下，但是这是一种罕见的发生），以无回直肌切除仅使用额下解剖需要;所有其他前床突上动脉瘤流通场所（包括后交通动脉）要求&lt;1厘米近端Sylivan裂缝剥离，露出床突上颈内动脉，其分支（后交通和脉络膜前动脉），颈内动脉末端，A1和M1起源，以及在近端A2和M 2段远端各自分叉。总外侧裂曝光是硬币大小（1毫升×1厘米），无脑拉钩被用于任何的报告的病例。重力依赖脑松弛足以用于在上面所讨论的区域进行手术夹子结扎所需的软组织结构和脉管系统的优良的曝光。 </li><li>使用双手manipula灰与手术microinstruments轻轻打开蛛网膜走廊，根据需要通过该曝光保持脑组织一旁与仪器手柄或抽吸装置的边缘。 注:高级作者的偏好是使用4-法国Fukishima吸嘴在非惯用手和优势手双极bayonettes为钝性剥离或microscissors为锐性剥离。湿润Telfa条被放置在脑表面上操纵以防止皮质损伤的部位。 Cottonoids常粘在脑表面，并且不能容易地前进更深的切割手术进行，而不会引起轻度皮质损伤。 </li><li>使用喉舌在手术显微镜频繁调整的范围和作为，同时保持双手在该领域需要关注的长度。 </li><li>固定在标准方式的动脉瘤，使用抽吸最常在非优势手保持外科走廊和可视免费的C的SF。 </li><li>经过剪辑的位置，进行术中多普勒动脉瘤圆顶确认流动停止，以及流入和流出的船只，以确认流程，仔细检查动脉瘤颈和家长的船只。我们保留术数字减影血管造影（DSA）为前交通动脉瘤和那些夹住动脉瘤，其中流入，流出，或动脉瘤颈不能完全显现，或者有与手术中多普勒关注。术DSA优于吲哚花青绿（ICG）血管造影，因为当多个动脉瘤夹被用来重建动脉瘤颈，夹子可以阻碍可视化。注意:一旦动脉瘤已经牢固夹住，显微镜从游戏场中去除和灌溉用生理盐水溶液大脑关闭后，以尽量减少性气的量。 </li><li>检查所述夹子用于动脉瘤闭塞的多普勒后，在动脉瘤圆顶是穿孔的机智<html>公顷22克针连接于静脉内管道和一个10毫升注射器和手动抽吸吸确认动脉瘤闭塞。 </li><li> Reapproximate天然硬膜用4-0 surgilon并覆盖有合成硬脑​​膜替代，如果防水密封不能够正确地得到。 </li><li>安全的骨板，每护理标准的金属电镀系统。 </li><li>固定抗天然骨骨瓣平齐的前缘，以避免两者之间的空间，这不会是美容上赏心悦目后组织愈合。 </li><li> Reapproximate颞肌筋膜间断2-0薇乔缝合。固定颞肌的顶部以2-0薇乔线迹到正面金属板到它reapproximate到颞线。 </li><li> Reapproximate使用3-0薇乔缝合帽状，它可以使用钉书钉，尼龙或普理灵关闭头皮以标准方式。扮靓每个医生的喜好无菌绷带。 </li></ol>_title"&gt; 4。治疗后护理<ol><li>治疗后患者承认的重症监护病房，并尽快镇静或全身麻醉逐渐消减足够的话，一般在6小时拔管与护理人员动员。 </li><li>排列的物理治疗和职业治疗，以便评估患者安全出院回家，如果有由护理人员任何问题开始手术后的第一天。 </li><li>燃放时满足条件的患者:疼痛控制，只能口服药物，独立排尿，独立走动，和容忍口头食物摄入量。 </li></ol>

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埃里克·德赛是医生顾问MicroVention公司，Covidien公司的神经血管，Integra生命科学公司。

颅内动脉瘤的手术夹子结扎保持在治疗某些类型的动脉瘤的一个相关和重要的选项，尽管这个作用已被削弱，在过去几年中作为血管内技术变得更安全和更有效。血管内介入治疗已超过手术的脑动脉瘤，但血管内治疗后复发率较高，偶尔需要进行动脉瘤复发从血管内治疗失败后手术治疗，具体的形态使得血管内治疗的风险较高，需要放置支架，以及最近的一些文献回顾累计血管内治疗比手术治疗?...

手术结扎夹已经治疗颅内动脉瘤的中流砥柱，但最近已经由微创腔内技术主要是取代1,2临床试验，包括未破裂颅内动脉瘤的国际学习（ISUIA-1和ISUIA-2），以及国际蛛网膜下腔动脉瘤试验（ISAT）已证明低发病率和死亡率，住院时间长度缩短，并降低整体的费用，与血管内治疗相比手术夹子结扎3 - 5然而，血管内治疗后的较高动脉瘤的复发率，导致了检查的累积风险的患者相比，手术夹子结扎。3,4-外科治疗仍然是动脉瘤治疗的重要方式，特别是对于具有形貌可能难以治疗与血管内装置的前循环动脉瘤。 6 - 8这些微创手术方法可减少住院的长度留，手术并发症，治疗费用，并改善患者的预后。9 在这里，我们提出我们的经验，以微创的方法来使用在一个大型三级脑血管中心进行的前循环动脉瘤翼点入路未破裂颅内动脉瘤手术结扎夹和比较的结果与年龄从全国住院样本数据集相匹配（NIS ）。该手术技术进行审查，包括病人的准备，放松大脑，外侧裂解剖和闭合。术后护理和排放要求也将被概述。

<table><tbody><tr><td>Mayfield Infinity skull clamp</td><td>Integra</td><td>A-1114</td><td></td></tr><tr><td>Mayfield table attachment</td><td>Integra</td><td>A-1018</td><td></td></tr><tr><td>4-French Fukishima suction tip</td><td>Integra</td><td>R-8986</td><td></td></tr><tr><td>Periosteal elevator (Langenbeck)</td><td>Codman</td><td>65-1116</td><td></td></tr><tr><td>Metzenbaum scissors</td><td>Codman</td><td>36-5023</td><td></td></tr><tr><td>Malis dissector, round angled</td><td>Codman</td><td>80-1541&amp;nbsp;</td><td></td></tr><tr><td>Penfield dissector, style 1</td><td>Codman</td><td>65-1015</td><td></td></tr><tr><td>Lempert bone rongeur</td><td>Codman</td><td>19-1232</td><td></td></tr><tr><td>Malis Irrigation Module</td><td>Codman</td><td>Module 1000</td><td></td></tr><tr><td>Bovie monopolar electrocautery device</td><td>Codman</td><td></td><td></td></tr><tr><td>Insulated blade for electrocautery device</td><td>Covidien</td><td>E1455</td><td></td></tr><tr><td>Fish-hook retractors</td><td>Lone Star</td><td>3350-8G</td><td></td></tr><tr><td>Pneumatic drill</td><td>Medtronic</td><td>Midas Rex MR7</td><td></td></tr><tr><td>Side-cutting drill</td><td>Medtronic</td><td>F2/8TA23</td><td></td></tr><tr><td>Fluted legend match head tool</td><td>Medtronic</td><td>10MH30</td><td></td></tr><tr><td>Surgical scalpel No. 10, 11, 15</td><td>Bard-Parker</td><td>0029064 (No.10), 0018291 (No.11), 0018043 (No.15)</td><td></td></tr><tr><td>Intra-operative microscope with mouthpiece</td><td>Leica</td><td></td><td></td></tr><tr><td>Microscissors</td><td>V. Mueller</td><td>NL3785-034(st), NL3785-035(cvd)</td><td></td></tr><tr><td>Rhoton dissector, #2</td><td>V. Mueller</td><td>NL3785-002&amp;nbsp;</td><td></td></tr><tr><td>Telfa strips</td><td>American Surgical</td><td>#80-09 (1/2x3), #80-04 (1/4x3)</td><td></td></tr><tr><td>Aneurysm clip</td><td>Aesculap</td><td></td><td></td></tr><tr><td>Raney clip applier</td><td>Aesculap</td><td>FF012R</td><td></td></tr><tr><td>Synthes Matrix metal plating system</td><td>Synthes</td><td></td><td></td></tr><tr><td>Braided absorbable surgical sutures (Vicyrl)&amp;nbsp;</td><td>Ethicon</td><td>J790D (3-0), J743D (4-0)</td><td></td></tr><tr><td>Braided nylon nonabsorbable surgical sutures (Nurolon) 4-0</td><td>Ethicon</td><td>C584D</td><td></td></tr><tr><td>Doppler System</td><td>Mizuho</td><td>07-150-02</td><td></td></tr></tbody></table>

minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms

微创手术方法为颅内动脉瘤夹闭可以减少住院时间，手术并发症，治疗费用长度，改善患者的预后。我们提出我们的经验，在一个大型三级脑血管中心进行的前循环动脉瘤微创翼点入路，并比较结果与来自全国住院样本（NIS）的年龄匹配的数据集。 2008年8月至2012年12月，患者≤55岁22选修瘤剪报由同一双奖学金训练有素的脑/神经外科血管内进行。 1例（4.5％）经历了短暂的术后并发症。 18 22例恢复为后续成像，并有经过22个月的平均持续时间没有复发。在NIS数据库2008至2010年进行搜索，也为年龄≤55岁的患者，取得了1,341住院的手术unrupt结扎夹被保险脑动脉瘤。逗留和住院费用使用微创拇指大小的翼点入路术住院长度在我们的机构几乎NIS的一半（停留时间:3.2比5.7天;住院费用:52779美元与101882美元）。微创拇指大小的翼点入路开颅允许未破裂小型和中型的前床突上循环动脉瘤良好的曝光。从键蛛网膜下腔水箱及恒定双手显微外科技术脑脊液引流避免需要拉钩可在牵开器站点造成挫伤，局部静脉梗塞，以及手术后的脑水肿。利用这套技术已经给我们的患者住院时间短以较低的成本比全国平均水平。

目前，在我们的机构超过150个动脉瘤，每年处理。 2008年8月至2012年12月，采用对病人≤55岁supraclinoidal这个动脉瘤微创拇指大小的翼点入路开颅术22选修瘤剪报由同一双奖学金训练有素的脑血管/血管内，发达国家这种技术的神经外科医生（EMD进行）（ 表1）。这个年龄组被选择作为早期试验显示，手术治疗动脉瘤的患者高于此年龄结果比血管内治疗，因此，55岁以上少数患者用手术夹子...

Watch this Scientific Journal Video about Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms at JoVE.com

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

微创拇指大小的翼点入路开颅动脉瘤夹闭已经给我们的患者住院时间短以较低的成本比全国平均水平。

微创拇指大小翼点入开颅未破裂前循环动脉瘤的手术夹子结扎

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

minimally-invasive-thumb-sized-pterional-craniotomy-for-surgical-clip

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

15.4K 次观看.  Crouse Neuroscience Institute. 微创拇指大小的翼点入路开颅动脉瘤夹闭已经给我们的患者住院时间短以较低的成本比全国平均水平。 

视频: Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Microvascular Decompression: Salient Surgical Principles and Technical Nuances

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports indicate that 80-90% of cases are related to compression of the trigeminal nerve by an adjacent vessel. The majority of patients with trigeminal neuralgia eventually require surgical management in order to achieve remission of symptoms. Surgical options for management include ablative procedures (e.g., radiosurgery, percutaneous radiofrequency lesioning, balloon compression, glycerol rhizolysis, etc.) and microvascular decompression. Ablative procedures fail to address the root cause of the disorder and are less effective at preventing recurrence of symptoms over the long term than microvascular decompression. However, microvascular decompression is inherently more invasive than ablative procedures and is associated with increased surgical risks. Previous studies have demonstrated a correlation between surgeon experience and patient outcome in microvascular decompression. In this series of 59 patients operated on by two neurosurgeons (JSN and PEK) since 2006, 93% of patients demonstrated substantial improvement in their trigeminal neuralgia following the procedure&#x2014;with follow-up ranging from 6 weeks to 2 years. Moreover, 41 of 66 patients (approximately 64%) have been entirely pain-free following the operation.
In this publication, video format is utilized to review the microsurgical pathology of this disorder. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed.

There are many available options for management of the patient with trigeminal neuralgia. Microvascular decompression, while the most invasive of all options, is also the most effective at achieving long term remission of symptoms. Video instruction on how to maximize efficacy and minimize complications with this procedure is described.

微血管减压：突出的手术原则和技术的细微差别

Trigeminal neuralgia is a disorder associated with severe episodes of lancinating pain in the distribution of the trigeminal nerve. Previous reports ...

科研

医学

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection

Stroke is a leading cause of death, disability, and socioeconomic loss worldwide. The majority of all strokes result from an interruption in blood flow (ischemia) 1. Middle cerebral artery (MCA) delivers a great majority of blood to the lateral surface of the cortex 2, is the most common site of human stroke 3, and ischemia within its territory can result in extensive dysfunction or death 1,4,5. Survivors of ischemic stroke often suffer loss or disruption of motor capabilities, sensory deficits, and infarct. In an effort to capture these key characteristics of stroke, and thereby develop effective treatment, a great deal of emphasis is placed upon animal models of ischemia in MCA.
Here we present a method of permanently occluding a cortical surface blood vessel. We will present this method using an example of a relevant vessel occlusion that models the most common type, location, and outcome of human stroke, permanent middle cerebral artery occlusion (pMCAO). In this model, we surgically expose MCA in the adult rat and subsequently occlude via double ligature and transection of the vessel. This pMCAO blocks the proximal cortical branch of MCA, causing ischemia in all of MCA cortical territory, a large portion of the cortex. This method of occlusion can also be used to occlude more distal portions of cortical vessels in order to achieve more focal ischemia targeting a smaller region of cortex. The primary disadvantages of pMCAO are that the surgical procedure is somewhat invasive as a small craniotomy is required to access MCA, though this results in minimal tissue damage. The primary advantages of this model, however, are: the site of occlusion is well defined, the degree of blood flow reduction is consistent, functional and neurological impairment occurs rapidly, infarct size is consistent, and the high rate of survival allows for long-term chronic assessment.

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection

We describe a highly reproducible method for the permanent occlusion of a rodent major cerebral blood vessel. This technique can be accomplished with very little peripheral damage, minimal blood loss, a high rate of long-term survival, and consistent infarct volume commensurate with the human clinical population.

永久性脑血管闭塞<em&gt;通过</em&gt;双人结扎横断

Stroke is a leading cause of death, disability, and socioeconomic loss worldwide. The majority of all strokes result from an interruption in blood flow ...

Microsurgical Clip Obliteration of Middle Cerebral Aneurysm Using Intraoperative Flow Assessment

Cerebral aneurysms are abnormal widening or ballooning of a localized segment of an intracranial blood vessel.  Surgical clipping is an important treatment for aneurysms which attempts to exclude blood from flowing into the aneurysmal segment of the vessel while preserving blood flow in a normal fashion.  Improper clip placement may result in residual aneurysm with the potential for subsequent aneurysm rupture or partial or full occlusion of distal arteries resulting in cerebral infarction.  Here we describe the use of an ultrasonic flow probe to provide quantitative evaluation of arterial flow before and after microsurgical clip placement at the base of a middle cerebral artery aneurysm.  This information helps ensure adequate aneurysm reconstruction with preservation of normal distal blood flow.

Description of the surgical obliteration of a cerebral aneurysm utilizing an ultrasonic flow probe to assess arterial flow prior to and after aneurysm clip placement.

显微剪辑闭塞大脑中动脉瘤术中流量评估

Cerebral aneurysms are abnormal widening or ballooning of a localized segment of an intracranial blood vessel.  Surgical clipping is an important ...

生物学

Lateral Chronic Cranial Window Preparation Enables In Vivo Observation Following Distal Middle Cerebral Artery Occlusion in Mice

Focal cerebral ischemia (i.e., ischemic stroke) may cause major brain injury, leading to a severe loss of neuronal function and consequently to a host of motor and cognitive disabilities. Its high prevalence poses a serious health burden, as stroke is among the principal causes of long-term disability and death worldwide1. Recovery of neuronal function is, in most cases, only partial. So far, treatment options are very limited, in particular due to the narrow time window for thrombolysis2,3. Determining methods to accelerate recovery from stroke remains a prime medical goal; however, this has been hampered by insufficient mechanistic insights into the recovery process. Experimental stroke researchers frequently employ rodent models of focal cerebral ischemia. Beyond the acute phase, stroke research is increasingly focused on the sub-acute and chronic phase following cerebral ischemia. Most stroke researchers apply permanent or transient occlusion of the MCA in mice or rats. In patients, occlusions of the MCA are among the most frequent causes of ischemic stroke4. Besides proximal occlusion of the MCA using the filament model, surgical occlusion of the distal MCA is probably the most frequently used model in experimental stroke research5. Occlusion of a distal (to the branching of the lenticulo-striate arteries) MCA branch typically spares the striatum and primarily affects the neocortex. Vessel occlusion can be permanent or transient. High reproducibility of lesion volume and very low mortality rates with respect to the long-term outcome are the main advantages of this model. Here, we demonstrate how to perform a chronic cranial window (CW) preparation lateral to the sagittal sinus, and afterwards how to surgically induce a distal stroke underneath the window using a craniotomy approach. This approach can be applied for sequential imaging of acute and chronic changes following ischemia via epi-illuminating, confocal laser scanning, and two-photon intravital microscopy.

Lateral Chronic Cranial Window Preparation Enables In Vivo Observation Following Distal Middle Cerebral Artery Occlusion in Mice

Surgical occlusion of a distal middle cerebral artery branch (MCAo) is a frequently used model in experimental stroke research. This manuscript describes the basic technique of permanent MCAo, combined with the insertion of a lateral cranial window, which offers the opportunity for longitudinal intravital microscopy in mice.

横向慢性颅窗口准备启用<em&gt;在体内</em&gt;观察继末节小鼠大脑中动脉闭塞

Focal cerebral ischemia (i.e., ischemic stroke) may cause major brain injury, leading to a severe loss of neuronal function and consequently to a host of ...

神经科学

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs must be tailored specifically to the lesion, with surgical resection being the gold standard for small, accessible lesions. Pre-operative embolization of AVMs can reduce nidal blood flow and remove high-risk AVM features such as intranidal or venous aneurysms, thereby simplifying a challenging neurosurgical procedure. Herein, we describe our approach for the staged endovascular embolization and open resection of AVMs, and highlight the advantages of having a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team. This includes planning the craniotomy and resection to immediately follow the final embolization stage, thereby using a single session of anesthesia for aggressive embolization, and rapid resection. Finally, we provide a representative case of a 22-year-old female with an unruptured right frontal AVM diagnosed during a seizure workup, who was successfully treated via staged embolizations followed by open surgical resection.

Surgery is the gold standard for accessible arteriovenious malformations (AVMs), and pre-operative embolization can simplify this procedure. We describe our approach for staged endovascular embolization and open resection of AVMs, and provide a representative clinical example highlighting the advantages of a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team.

脑动静脉畸形的综合血管内和开放性手术治疗

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs ...

Surgical Approach for Middle Cerebral Artery Occlusion and Reperfusion Induced Stroke in Mice

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ischemic in origin and occur in the territory of the middle cerebral artery (MCA). Currently the only Food and Drug Administration (FDA) approved drug for the treatment of this devastating disease is tissue plasminogen activator (tPA). However, tPA has a small therapeutic window for administration (3 - 6 hr), and is only effective in 4% of the patients who actually receive it. Current research focuses on understanding the pathophysiology of stroke in order to find potential therapeutic targets. Thus, reliable models are crucial, and the MCA occlusion (MCAo) model (also termed the intraluminal filament or suture model) is deemed to be the most clinically relevant surgical model of ischemic stroke, and is fairly non-invasive and easily reproducible. Typically the MCAo model is used with rodents, especially with mice due to all the genetic variations available for this species. Here we describe (and present in the video) how to successfully perform the MCAo model (with reperfusion) in mice to generate reliable and reproducible data.

In order to understand the pathophysiology of stroke, it is important to use reliable models. This paper will describe one of the most frequently used stroke models in mice, termed the middle cerebral artery occlusion (MCAo) model (also termed the intraluminal filament or suture model) with reperfusion.

对大脑中动脉闭塞再灌注损伤诱发中风小鼠的手术方法

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ...

Development of a Cadaveric Multiport Model of Posterior Circulation Aneurysm Clipping for Neurosurgery and Otolaryngology Residents

Posterior circulation aneurysms are difficult to treat with the current methods of coiling and clipping. To address limitations in training, we developed a cadaveric model to train learners on endoscopic clipping of posterior circulation aneurysms. An endoscopic transclival approach (ETA) and a transorbital precaruncular approach (TOPA) to successfully access and clip aneurysms of the posterior circulation are described. The model has flexibility in that a colored silicone compound can be injected into the cadaveric vessels for the purpose of training learners on vascular anatomy. The other option is that the model could be connected to a vascular perfusion pump allowing real-time appreciation of a pulsatile or ruptured aneurysm. This cadaveric model is the first of its kind for training of endoscopic clipping of posterior circulation aneurysms. Learners will develop proficiency in endoscopic skills, appropriate dissection, and appreciation for relative anatomy while developing an algorithm that can be employed in a real operative arena. Going forward, various clinical scenarios can be developed to enhance the realism, allow learners from different specialties to work together, and emphasize the importance of teamwork and effective communication.

A model protocol to train neurosurgery and otolaryngology resident learners on endoscopic transclival clipping of posterior circulation aneurysms is described. Two endoscopic approaches to access the silicone-injected or perfused posterior circulation of cadaveric heads are established for training. Learners are tasked with clipping of posterior circulation based on clinical scenarios.

Posterior circulation aneurysms are difficult to treat with the current methods of coiling and clipping. To address limitations in training, we developed ...

Middle Cerebral Artery Occlusion Allowing Reperfusion via Common Carotid Artery Repair in Mice

The ischemic stroke is a major cause of adult long-term disability and death worldwide. The current treatments available are limited, with only tissue plasminogen activator (tPA) as an approved drug treatment to target ischemic strokes. Current research in the field of ischemic stroke focuses on better understanding the pathophysiology of stroke, to develop and investigate novel pharmaceutical targets. Reliable experimental stroke models are crucial for the progression of potential treatments. The middle cerebral artery occlusion (MCAO) model is clinically relevant and the most frequently used surgical model of ischemic stroke in rodents. However, the outcomes of this model, such as lesion volume, are associated with high levels of variability, particularly in mice. The alternative MCAO model described here allows the reperfusion of the common carotid artery (CCA) and the increased perfusion of the middle cerebral artery (MCA) territory, using a tissue pad with fibrinogen-based sealant to repair the vessel, and the improved welfare of the mice by avoiding external carotid artery (ECA) ligation. This reduces the reliance on the Circle of Willis, which is known to be highly anatomically variable in mice. Representative data show that using this alternative surgical approach decreases the variability in lesion volumes between the traditional MCAO approach and the alternative approach described here.

Intraluminal filament occlusion of the middle cerebral artery is the most frequently used in vivo model of experimental stroke in rodents. An alternative surgical approach to allow common carotid artery repair is performed here, which allows the reperfusion of the common carotid artery and a full reperfusion to the middle cerebral artery territory.

颅内动脉闭塞允许经普通颈动脉修复再灌注的研究

The ischemic stroke is a major cause of adult long-term disability and death worldwide. The current treatments available are limited, with only tissue ...

Creation of Two Saccular Elastase-Digested Aneurysms with Different Hemodynamics in One Rabbit

Preclinical animal models with hemodynamic, morphologic, and histologic characteristics close to human intracranial aneurysms play a key role in the understanding of the pathophysiological processes and the development and testing of new therapeutic strategies. This study aims to describe a new rabbit aneurysm model that allows the creation of two elastase-digested saccular aneurysms with different hemodynamic conditions within the same animal.
Five female New Zealand white rabbits with a mean weight of 4.0 (&#177; 0.3) kg and mean age of 25 (&#177;5) weeks underwent microsurgical stump and bifurcation aneurysm creation. One aneurysm (stump) was created by right common carotid artery (CCA) exposure at its origin at the brachiocephalic trunk. A temporary clip was applied at the CCA origin and another, 2 cm above. This segment was treated with a local injection of 100 U of elastase for 20 min. A second aneurysm (bifurcation) was created by suturing an elastase-treated arterial pouch into the end-to-side anastomosis of the right CCA to left CCA. Patency was controlled by fluorescence angiography immediately after creation.
The average duration of surgery was 221 min. The creation of two aneurysms in the same animal was successful in all rabbits without complication. All aneurysms were patent immediately after surgery except for one bifurcation aneurysm, which showed an extreme tissue reaction due to elastase incubation and an immediate intraluminal thrombosis. No mortality was observed during surgery and up to one-month follow-up. Morbidity was limited to a transient vestibular syndrome (one rabbit), which recovered spontaneously within one day.
Demonstrated here for the first time is the feasibility of creating a two-aneurysm rabbit model with stump and bifurcation hemodynamic characteristics and highly degenerated wall conditions. This model allows the study of the natural course and potential treatment strategies on the basis of aneurysm biology under different flow conditions.

This protocol describes the steps for the creation of a rabbit model with two elastase-digested aneurysms with different hemodynamics (stump and bifurcation constellation). This allows the testing of novel endovascular devices in aneurysms with different angioarchitecture and hemodynamic conditions within a single animal.

在一只兔中产生两个具有不同血流动力学的囊状弹性蛋白酶消化动脉瘤

Preclinical animal models with hemodynamic, morphologic, and histologic characteristics close to human intracranial aneurysms play a key role in the ...

Optimization of the Longa Middle Cerebral Artery Occlusion Method for Complete Reperfusion

The middle cerebral artery occlusion model serves as the primary animal model for studying ischemic stroke. Despite being used in research for over three decades, its standardization remains inadequate. Predominantly conducted on rats and mice, the procedure poses challenges due to mice's smaller and more fragile nature. Unlike the Koizumi common carotid artery method, the Longa external carotid artery is the sole intraluminal filament stroke model ensuring complete reperfusion post-ischemia. This aspect holds critical significance for studies investigating reperfusion phenomena. The surgical modifications demonstrated in this article ensure continuous blood flow from the common carotid artery throughout the ischemic phase and after the reperfusion onset. The goal of these modifications is to selectively occlude the middle cerebral artery by keeping the perfusion uninterrupted in branches proximal to the middle cerebral artery during the ischemia period. Furthermore, the onset of reperfusion is sudden and can be precisely controlled, thereby modeling endovascular thrombectomy in human medicine more accurately. Our aim in presenting this comprehensive video article is to ease the training of new surgeons and promote the standardization of surgical procedures within the scientific community.

This protocol presents a step-by-step guide for researchers to perform the middle cerebral artery occlusion procedure on mice using the modified Longa external carotid artery method. Modifications presented in this article aim to increase the accuracy of middle cerebral artery occlusion and ensure complete reperfusion.

Longa 大脑中动脉闭塞方法的优化

The middle cerebral artery occlusion model serves as the primary animal model for studying ischemic stroke. Despite being used in research for over three ...

微创拇指大小翼点入开颅未破裂前循环动脉瘤的手术夹子结扎

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