A2 aneurysm surgery steps

Post op CT angio of clipped A2 aneurysm  

 Aneurysms beyond A Com on anterior cerebral arteries can occur at many places. Proximal A2 artery aneurysms are not that uncommon. Author has experience of clipping aneurysms at this location and has developed steps to clip such aneurysms. One such aneurysm was clipped today in an adult male who had presented with bleed in right frontal lobe and in cistern of lamina terminalis.  I follow the following steps-

-Patient is put in supine position, head strictly in midline and neck extended 20 to 30 degree. The head end is also elevated to 30 degree and no 3 pin fixation is done. To keep head still a bandage is applied over a cotton pad to fix head to head end of table.

- Frontotemporal free bone flap is raised using Karam Chand method of craniotomy. Flap goes right up to midline exposing anterior part of sagittal sinus. Lesser wing of sphenoid is nibbled, middle meningeal artery is tied and coagulated. Drill holes are made all around to pass hitch sutures, which are taken but not tied.

-2 to 4 needles are applied to suction tube to reduce suction pressure substantially.

- Dura is opened parallel to superior orbital margin and inferiorly beyond lesser wing of sphenoid. A no 12 or 14 Foley catheter is passed below dura and inflated upto 7cc to expand subarachnoid space, subsequently deflated and taken out.. Then Leyla retractor is applied and sylvian fissure is opened to drain csf. If mannitol has not relaxed brain Lasix is given and anaesthetic gases are reduced to minimum.

-After brain is relaxed, Leyla is removed from over sylvian fissure and anteriorinterhemispheric fissure is opened . Leyla retractor is  placed to retract frontal lobe laterally.

-A2 areteries are identified and traced proximally. Part of A2 anterior to aneurysm is also identified for placing temporary clip, if needed. Low suction pressure and sharp dissection minimizes the aneurysmal rupture and need for temporary clip.

Aneurysm neck is identified and clipped.

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