Middle cerebral artery aneurysms (MCANs) associated with short M1 located in the limen insulae tend to have poor outcomes after surgical clipping due to brain contusions and ischemic complications. However, the effect of veins in the deep Sylvian fissure is unclear. The normal variant of the
The safety and efficacy of the ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, Cincinnati, OH) for carotid endarterectomy (CEA) were evaluated. Material and Methods: CEA was performed in 28 consecutive patients (27 men, 1 woman; mean age, 72 years) using the ultrasonic scalpel from April 2011 to October 2012. Eighteen cases involved high-position stenosis. Mean percentage stenosis was 78%. Complications were compared to those in 27 consecutive cases treated without the ultrasonic scalpel, performed prior to March 2011. Results: One patient treated using the ultrasonic scalpel suffered ischemic complication (not significant). No patient using the ultrasonic scalpel died (not significant). Five patients treated using the ultrasonic scalpel showed increased signal hyperintensity on postoperative diffusion-weighted magnetic resonance imaging (not significant). Four patients treated using the ultrasonic scalpel suffered transient hoarseness, including 1 patient with recurrent nerve paralysis (not significant). However, only 3 of the 18 patients treated using the ultrasonic scalpel with high-position stenosis suffered transient hoarseness, showing a significant decrease compared to the 6 of 11 patients with high-position stenosis treated without the ultrasonic scalpel (P<0.05). Discussion: The ultrasonic scalpel reportedly causes less heat injury to vessels than electrocautery, which may account for the reduced number of complications caused by temporary damage to the superior laryngeal nerve. Conclusion: The ultrasonic scalpel is a useful tool for CEA, particularly for high-position stenosis.
Clipping through a keyhole minicraniotomy is a modern option for treating cerebral aneurysms and is less invasive than standard craniotomy. We report the findings of 240 consecutive keyhole clipping surgeries performed in 231 patients aged 34-79 years (mean 63 ± 9 years), resulting in the treatment of 251 unruptured anterior circulating aneurysms. The aneurysms were relatively small (<10 mm). Anterior communicating artery aneurysms (57 cases) and internal carotid artery aneurysms (44 cases) were treated through the supraorbital keyhole (mean size, 29 ± 3 mm) approach (Perneczky method). Middle cerebral artery aneurysms (139 cases) were treated through the pterional keyhole (mean size, 25 ± 2 mm) approach. Each surgery was individualized by using detailed preoperative simulation based on three-dimensional computed tomography angiography.Neck clipping was performed for 244 aneurysms (97%); wrapping was done for 3 aneurysms due to blister or motor-evoked potential abnormality; and neck remnant was identified in 4 aneurysms. Complete stroke occurred in 1 patient and mild dementia in 1 patient. Lacunar infarction developed in 6 patients (2.5%; 2 symptomatic, 4 asymptomatic); however, there were no hemorrhagic complications.Frontalis muscle palsy persisted in 5 patients (2.1%), and chronic subdural hematoma was treated surgically in 13 patients (5.4%). The outcomes at 3 months were score 0 (99.2%), score 1 (0.4%), and score 3 (0.4%) on the modified Rankin scale, and 212 patients (92%) were discharged within 3 days after surgery. The keyhole approach is an effective and minimally invasive treatment option for relatively small unruptured aneurysms.
Basilar artery and internal carotid paraclinoid aneurysms are still surgically challenging. We performed 31 clipping surgeries (basilar tip aneurysm 6, basilar artery-superior cerebellar artery aneurysm 8, and internal carotid aneurysm 17) via the extradural temporopolar approach. After the frontotemporal craniotomy, the meningo-orbital band was incised and the dura propria of the temporal lobe was peeled from the lateral wall of the cavernous sinus. The
Introduction:The ultrasonic scalpel (Harmonic Scalpel; Ethicon, CO) can peel arteries from collagen-poor tissues, including adipose tissue, without damage to the arteries themselves. This procedure has been applied to skeletonization such as of an internal thoracic artery in the field of cardiac surgery and has become widespread. We have recently performed harvesting of the superficial temporal artery (STA) using an ultrasonic scalpel for bypass surgery, but reports of such procedures in the neurosurgical field has been rare. We herein investigated histological changes to the STA for safety assessment. Material and Method: Bypass surgery was performed in 15 consecutive patients (mean age, 62 years; range, 34-80 years; atheroma, n=10; moyamoya disease, n=3; arterial dissection, n=2) from January 2012 to February 2014. Twenty-two STA specimens were peeled using the ultrasonic scalpel and evaluated histologically. Results: Degeneration of the vascular wall was found in adventitia to media in 1 specimen (5%), and adventitia alone in 4 specimens (18%). No specimens showed intimal degeneration (0%). Conclusion: STA harvesting by ultrasonic scalpel can be performed safely, although thermal injury was histologically evident in 23% of the 15 cases (22 specimens) examined. Some mastery of skills is needed for further safety.
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