Wednesday 25 march 2009
3
25
/03
/Mar
/2009
14:50
Preoperative Diagnosis: Left posterior communicating artery aneurysm.
Postoperative Diagnosis: Left posterior communicating artery aneurysm.
Procedure Performed: Left pterional craniotomy for clip ligation, posterior communicating artery aneurysm.
Anesthesia: General endotracheal.
Estimated Blood Loss: Minimal.
Complications: None.
Details of Procedure: After informed consent was obtained, the patient was brought to the operating room. General anesthesia was induced, and the patient was smoothly intubated. His head was placed in Mayfield headholder. His head was turned to the right side 20 degrees, extended in the vertex position. The left side of his head was prepped and draped sterilely.
A curvilinear incision was made from 1 cm anterior to the tragus, through the zygoma, extending superiorly and then curving anteriorly to the point of mid pupillary line on his forehead. The subgaleal space was encountered and Raney clips were placed. The skin flap was reflected inferiorly and anteriorly. A fascial splitting dissection was performed at the deep portions of the temporalis muscle. The temporalis muscle was incised just inferior to the temporal line and the muscle was cauterized. The temporalis muscle was reflected inferiorly and anteriorly using periosteal elevator, and was held in place with hooks.
Pterional craniotomy was performed and bone flap was elevated without difficulty. The dura was intact after removal of the bone. The greater wing of the sphenoid was drilled until the superior lateral orbital walls were well skeletonized. The dura was opened in a curvilinear fashion based over the coronoid process and reflected inferiorly and held in place with tack-up sutures. The sylvian fissure was opened slightly to release spinal fluid. The frontal lobe was retracted superiorly until the carotid and optic nerve cisterns were encountered. These were opened sharply to release more CSF. The medial margin of the carotid artery was carefully dissected until proximal control of the carotid artery was achieved. A large, narrow-necked aneurysm was noted along the posterior lateral wall of the carotid artery.
A straight Yasargil clip was placed after dissection of the neck of the aneurysm, deflating the aneurysm completely. Dissection after the aneurysm was clipped revealed an intact anterior carotid artery and posterior communicating artery. The third nerve was identified and noted to be free of compression. The entire subdural space was irrigated.
The dura was closed primarily and tack-up sutures were placed. The bone was replaced with three 2-hole microplates. The temporalis muscle was reattached to the fascial border and subdural space was irrigated. A 10-French round J-P drain was placed. The galea was closed with interrupted 2-0 Vicryl stitches. The skin was closed with staples. A sterile dressing was applied. The Mayfield headholder was released. The head was wrapped.
The patient was awakened from anesthesia, extubated, and transported to the recovery room in excellent condition, after tolerating the procedure well. There were no complications.
Postoperative Diagnosis: Left posterior communicating artery aneurysm.
Procedure Performed: Left pterional craniotomy for clip ligation, posterior communicating artery aneurysm.
Anesthesia: General endotracheal.
Estimated Blood Loss: Minimal.
Complications: None.
Details of Procedure: After informed consent was obtained, the patient was brought to the operating room. General anesthesia was induced, and the patient was smoothly intubated. His head was placed in Mayfield headholder. His head was turned to the right side 20 degrees, extended in the vertex position. The left side of his head was prepped and draped sterilely.
A curvilinear incision was made from 1 cm anterior to the tragus, through the zygoma, extending superiorly and then curving anteriorly to the point of mid pupillary line on his forehead. The subgaleal space was encountered and Raney clips were placed. The skin flap was reflected inferiorly and anteriorly. A fascial splitting dissection was performed at the deep portions of the temporalis muscle. The temporalis muscle was incised just inferior to the temporal line and the muscle was cauterized. The temporalis muscle was reflected inferiorly and anteriorly using periosteal elevator, and was held in place with hooks.
Pterional craniotomy was performed and bone flap was elevated without difficulty. The dura was intact after removal of the bone. The greater wing of the sphenoid was drilled until the superior lateral orbital walls were well skeletonized. The dura was opened in a curvilinear fashion based over the coronoid process and reflected inferiorly and held in place with tack-up sutures. The sylvian fissure was opened slightly to release spinal fluid. The frontal lobe was retracted superiorly until the carotid and optic nerve cisterns were encountered. These were opened sharply to release more CSF. The medial margin of the carotid artery was carefully dissected until proximal control of the carotid artery was achieved. A large, narrow-necked aneurysm was noted along the posterior lateral wall of the carotid artery.
A straight Yasargil clip was placed after dissection of the neck of the aneurysm, deflating the aneurysm completely. Dissection after the aneurysm was clipped revealed an intact anterior carotid artery and posterior communicating artery. The third nerve was identified and noted to be free of compression. The entire subdural space was irrigated.
The dura was closed primarily and tack-up sutures were placed. The bone was replaced with three 2-hole microplates. The temporalis muscle was reattached to the fascial border and subdural space was irrigated. A 10-French round J-P drain was placed. The galea was closed with interrupted 2-0 Vicryl stitches. The skin was closed with staples. A sterile dressing was applied. The Mayfield headholder was released. The head was wrapped.
The patient was awakened from anesthesia, extubated, and transported to the recovery room in excellent condition, after tolerating the procedure well. There were no complications.
