ANEURYSM CLIP VIVA VOCE ; SURGICAL PEARLS FOR THE ANESTHESIOLOGIST / 'SAFE Anesthesiologist' Series [Surgical Aspects For Empowering the Anesthesiologist]

❓CAN YOU TELL A FEW SITUATIONS WHERE ENDOVASCULAR THERAPY MAY BE A BETTER OPTION THAN SURGERY?

🅰 Aneurysms in elderly patients, in patients with poor neurological condition, in patients presenting with cerebral vasospasm, 

aneurysms that are difficult to surgically access and multiple aneurysms requiring multiple craniotomies for treatment

❓ CAN YOU TELL A FEW SITUATIONS WHERE SURGERY MAY BE A BETTER OPTION THAN ENDOVASCULAR THERAPY?

🅰  fusiform, blister-like, very small, very large, thrombotic, and wide-necked aneurysms, in patients presenting with a clinically significant intracerebral hemorrhage

❓CAN YOU TELL A FEW ADJUNCTS WHICH THE SURGEON MAY USE OR MAY ASK FROM THE ANESTHESIOLOGIST TO MINIMIZE THE RISK OF DIRECT BRAIN INJURY

🅰 Good bony removal to minimize or eliminate brain retraction, meticulous microsurgical dissection to preserve veins, pharmacologic brain protection or bypass procedures to reduce the risk of ischemic injury, use of temporary clips to reduce the risk of intraoperative rupture, and intraoperative imaging with digital subtraction angiography or indocyanine green videoangiography to verify surgical results

❓WHAT IS THE PROBLEM IF THE BONE DRILLING / EXPOSURE IS LESS THAN ADEQUATE 

🅰 Surgeon will be forced to use more brain retraction throughout the surgery , which may result in direct brain injury and thus  increase the chances of postoperative complications 

❓WHAT IS THE PROBLEM IF THE SURGEON OVERLOOK THE IMPORTANCE OF PRESERVING THE VEINS WHILE FOCUSING ON THE ARTERIAL ANATOMY 

🅰This can hamper venous drainage and can result in devastating venous congestion and infarction, postoperatively

❓WHAT ARE THE METHODS AVAILABLE TO PROLONG ISCHEMIC TOLERANCE TIMES DURING TEMPORARY CLIPPING

🅰 Burst suppression using Propofol or Barbiturates, induced hypertension, Hypothermia

❓ WHAT IS THE MAJOR ADVANTAGE OF SURGICAL CLIP LIGATION OF ANEURYSM OVER ENDOVASCULAR OPTIONS

🅰 Low risk of recurrence, if the clipping has been appropriate

❓WHAT ALL METHODS ARE AVAILABLE FOR THE SURGEON  IN DETERMINING WHETHER THE ANEURYSM IS COMPLETELY OBLITERATED AFTER CLIPPING

🅰 Puncturing the dome of the aneurysm after clipping and observe for refilling, Intraoperative angiography, indocyanine green videoangiography ( Indocyanine green dose : 0.2-0.5mg/kg bolus, max daily dose= 5mg/kg  )

❓ WHAT ALL METHODS ARE AVAILABLE FOR THE SURGEON  IN DETERMINING WHETHER THERE IS ANY COMPROMISE OF PARENT VESSEL AFTER CLIPPING

🅰intraoperative angiography,  Indocyanine green videoangiography and Microvascular doppler

❓ WHAT ARE THE METHODS AVAILABLE FOR THE SURGEON TO AVOID INTRAOPERATIVE RUPTURE OF THE ANEURYSM

🅰 Adequate exposure, sharp dissection, proximal control, and use of temporary clips. For proximal carotid aneurysms, control may require exposure of the cervical carotid, which also allows the surgeon to trap the aneurysm and to use suction decompression

❓IN THE EVENT OF AN UNTIMELY INTRAOPERATIVE RUPTURE OF AN ANEURYSM, WHAT ARE THE METHODS AVAILABLE FOR CONTROLLING THE BLEEDING

🅰 In this situation the tasks for the surgeon are: (1) Control bleeding (2) Repair the aneurysm & (3) Repair the arterial defect. For controlling the bleeding many techniques have been described, including use of a large-bore suction over the bleeding site , tamponade with a cottonoid, proximal temporary occlusion or trapping, carotid compression, coagulation of the aneurysmal rent, clip application to the distal sac, and induced hypotension. Sometimes the surgeon may ask for an Adenosine induced flow arrest, for placing the clip.

Reference: Chaper 13, Intraoperative Misadventures: Complication Avoidance and Management in Aneurysm Surgery

Daniel L. Barrow, Clinical Neurosurgery, Volume 58, 2011, The Congress of Neurological Surgeons