Microneurosurgical Atlas

277 Pages·1985·30.387 MB·English

by  Kenichiro Sugita M.D., Shigeaki Kobayashi M.D. (auth.)

Kenichiro Sugita
Microneurosurgical
Atlas
With the Assistance of Shigeaki Kobayashi
With 456 Figures
(Including 202 Colored Illustrations by the Author)
Springer-Verlag
Berlin Heidelberg NewY ork Tokyo
KENICHIRO SUGITA, M.D.
Professor and Head
SHIGEAKI KOBAYASHI, M.D.
Associate Professor
Department of Neurosurgery
School of Medicine
Shinshu University
Asahi 3-1-1, Matsumoto, 390 Japan
ISBN-13: 978-3-642-64906-6 e-ISBN-13: 978-3-642-61669-3
DOl: 1O.l 007/978-3-642-61669-3
Library of Congress Cataloging in Publication Date. Sugita, Kenichiro,
1932- . Microneurosurgical atlas. Bibliography: p. . Includes index.
1. Nervous system-Surgery-Atlases. 2. Microsurgery-Atlases. I. Title.
[DNLM: 1. Microsurgery-atlases. 2. Neurosurgeryatlases. WL 17
S947m] RD593.S77 1985 617'.48 85-2603
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© by Springer-Verlag Berlin Heidelberg 1985
Softcover reprint of the hardcover I st edition 1985
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al use.
Reproduction of the illustrations: Universitatsdruckerei H. Stiirtz AG,
Wiirzburg.
Preface _____________________________________________________v
The operations I perform every year never fail to provide me structed as they would appear with considerable retraction
with new insights into the practice of neurosurgery, and lead of the brain, though the actual field was usually no more
me not infrequently to new ideas concerning surgical tech than one third or one fourth of that shown; cotton patties
niques or equipment. The present work is a kind of surgical used for covering the cortex are omitted in the drawings.
diary of a neurosurgeon who, he would like to think, is ever In the majority of cases I performed the operation with my
improving his skills. Although there have already been many associates, all of whom have more than 10 years' clinical expe
distinguished publications, the book will, I believe, be of par rience in neurosurgery. Such splendid teamwork as exists in
ticular help to young neurosurgeons. our group is one of the most important factors in successful
I perform only a hundred or so operations a year, selected surgery, and for this purpose our system of stereoscopic assis
because of their technical difficulty. As difficult or unusual tant microscopes is indispensable. I wish to extend my war
cases are rather few, it is important that every practising neu mest thanks for their constant support to all my associates
rosurgeon should record those he encounters in exact detail. in the university hospitals of Shin shu and Nagoya and in
I would like especially to suggest to young surgeons that they the affiliated hospitals of Aizawa, Showainan, Seguchi, Ko
draw detailed operative pictures of such cases, as I have done. moro, Shinonoi, Kobayashi, Suwa and Nagoya Red Cross,
The collection will become an important and valuable private Chukyo, Ohgaki, Y okkaichi, Ichinomiya, Tajimi, Tosei, Oka
text in the future. zaki, Handa, Anjo, Nishio, Toyohashi, and Saiseikai-Shi
In the past 18 years I have performed about 2000 operations zuoka.
under the microscope. I have selected for this atlas about To my mentors, Dr. YOSHIYA MIURA, Prof. NAOKI KAGEYAMA,
100 of the cases I have dealt with in the past 8 years. I treat Prof. GENYO MITARAI, Prof. KEIICHI MURATA, Prof. HAJIME
the technical problems of each operation in considerable de NAGAI and Prof. OSAMU SATO at Nagoya University and Prof.
tail, and I have included all my unsuccessful cases as they TRAUGOTT RIECRERT and Prof. ROLF HASSLER at the Universi
taught me more than the successful ones. I drew each picture ty of Freiburg, lowe a great and long-standing debt of grati
of the operative findings from memory soon after the opera tude. My thanks are due also to Mr. P.E. DAVENPORT of
tion, without the aid of photographs or videotapes, and there Shinshu University at editing the English and to Mr. JORG
may therefore be occasional minor inaccuracies in the anatom K URN of Springer Verlag in Heidelberg, a medical illustrator
ical relationships or size. In particular, the size of an aneurysm of unique talent, for valuable suggestions. Lastly I wish to
or tumor may sometimes have been represented larger than thank the publishers for their friendly cooperation in the prep
it actually was; this is a common problem in immediate post aration and publication of the work.
operative drawings. The operating fields have been recon- KENICHIRO SUGITA
Contents ____________________________________________________
V_I1
I General Considerations 3 Anterior Communicating Artery Aneurysm 44
Case 15 Direct Retraction of Body (rt) . . . 44
1 Patient's Position .... 1 Case 16 Temporary Clipping (rt) ..... 46
2 Skin Incision and Bone Flap 2 Case 17 Double Clipping: Clip Blade Covered with
3 Retraction of the Brain . . 2 Silastic Tube (rt) . . . . . . 48
4 Preservation of Bridging Veins 2 Case 18 Double Clipping (rt) .... 50
Case 19 Two Cases with Ring Clip (1t) 52
Case 20 Giant Aneurysm (1t) .... 54
II Instrumentation
4 Distal Anterior Cerebral Artery Aneurysm 56
1 Operating Microscope 3
General Considerations . . . . . . . . . 56
2 Operating Chair 4
3 Operating Table 4 Case 21 Prevention of Narrowing of the Parent Artery
4 Instrument Table 5 (Two Clips) (rt) ............. 56
5 Head Frame and Multipurpose Head Frame 6 Case 22 Prevention of Narrowing of the Parent Artery
6 Self-Retaining Retractor and Tapered Brain (Three Clips) (rt) . . . . . . . 58
Retractor (Spatula) 6 Case 23 Large Aneurysm (Two Clips) (rt) . . . . . . 60
7 Bipolar Forceps 7
8 Suction 7
B Aneurysms of the Posterior Circle of Willis 62
9 Silver Dissector 9
10 Four-Pronged Hook 9 General Considerations for Basilar Artery Aneurysms 62
11 Cotton Patty . . . 9
12 Microscope Sterilization 9 1 Basilar Bifurcation Aneurysm . . . . . 66
Case 24 Anteriorly Projecting Aneurysm (rt) 66
Case 25 Retraction of Three Arteries (rt) 68
III Aneurysm
Case 26 Clipping Between Perforators (rt) . 70
Case 27 Application of Straight Ring Clip (rt) 72
General Considerations in Surgery of Aneurysms 10
Case 28 Clipping Through the Opticocarotid Space (rt) 74
Case 29 Puncture of Body (rt) . . 76
A Aneurysms of the Anterior Circle of Willis 15
Case 30 Unc1ipped Aneurysms (rt) . . . . . . 78
1 Carotid Artery Aneurysm . . . . . . . 16
2 Basilar-Superior Cerebellar Artery Aneurysm 82
Case 1 Ophthalmic Artery Aneurysm: Optic Nerve
General Considerations . . . . . . . . . . . 82
Retraction (rt) ........ 16
Case 2 Triple Aneurysm (rt) ......... 18 Case 31 Double Clipping (rt) .... . . . . 82
Case 3 Carotid Bifurcation Aneurysm (rt) . . . . 20 Case 32 Intraoperative Shortening of the Blade (rt) 84
Case 4 Medially Projecting Aneurysm: Clipping and Case 33 Direct Retraction of Aneurysm (1t) . 86
Puncture (rt) . . . . . . . . . . . . . 22 Case 34 Approach Above the Carotid Artery
Case 5 Ventrally Protruding Aneurysm Obliterated Bifurcation (rt) ............. 88
with Ring Clip (1t) .......... 24 Case 35 Unc1ipped Aneurysm with Bilateral Approach 90
Case 6 Aneurysm with Trigeminal Neuralgia (rt) . 26 Case 36 Distal Superior Cerebellar Artery Aneurysm
Case 7 Wide-Necked Aneurysm Obliterated with Two (1t) . . . . . . . . . . . . . . . . .. 92
Ring Clips (1t) ............. 28
Case 8 Large Aneurysm Obliterated with Two Ring 3 Proximal Posterior Cerebral Artery (Pi) Aneurysm 94
Clips (1t) . . . . . . . . . . . . . . .. 30
Case 37 Trapping of P1 (rt) . . . . . . . . . .. 94
Case 9 Large Aneurysm Obliterated with Three Clips
Case 38 Angled Ring Clip: Associated with A VM (1t) 96
(rt) ........... 32
Case 39 Associated with Agenesis of the Carotid
Artery (1t) . . . . . . . . . . . . 98
2 Middle Cerebral Artery Aneurysm 34
Case 10 Large Aneurysm Obliterated with Two Clips
4 Distal Posterior Cerebral Artery Aneurysm 101
(rt) . . . . . . . . . . . . . . . . .. 34
General Considerations . . . . . . . . . . 101
Case 11 Giant Aneurysm Obliterated with Two Long
Clips (It) ............... 36 Case 40 Removal of the Parahippocampal Gyrus (rt) 102
Case 12 Large Aneurysm: Body Clipping (It) 38 Case 41 Double Clipping in a Case Associated with
Case 13 Dilatation of the Trifurcation: Clipping and TIA (1t) . . . . . . . . . . . . . 104
Wrapping (1t) ............ 40 Case 42 Giant Aneurysm: Cutting and Double
Case 14 Giant Aneurysm: Clipping and Removal (rt) 42 Clipping (rt) . . . . . . . . . . . . . . . 106
VIII Contents
5 Basilar Trunk Aneurysm 108 7 Posterior Fossa AVM 172
Case 43 Double Aneurysm via Transsylvian Approach Case 73 In the Vermis: Concorde Position (Bilateral) 172
(rt) . . . . . . . . . . . . . 108 Case 74 Giant AVM in the Vermis (Bilateral) 174
Case 44 Direct Retraction of the Pons (1t) 110 Case 75 In the Tonsil (rt) . . . . . . . . . . . . . 176
Case 45 Vertebral Union (rt) ..... 112
Case 46 Giant Aneurysm: Un clipped (rt) 114 8 Hemangioma ... . . . . . . . . . . . .. 178
6 Vertebral Artery Aneurysm . . . . . 116 Case 76 Feeding from the Superior Cerebellar Artery
(rt) . . . . . . . . . . . . . . 178
General Considerations . . . . . . . . 116
Case 77 In the Cerebellopontine Angle (1t) 180
Case 47 Bayonet Clip for a Large Aneurysm (rt) 118 Case 78 Cerebellar . . . . . . . . . . . 182
Case 48 Clipping by Interchange of Two Clips (It) 120
Case 49 Aneurysm Close to a Midline (rt) 122
Case 50 Aneurysm Close to a Midline (1t) 124
Case 51 Body Clipping (rt) . . . . . . 126
V Meningioma
Case 52 Body Clipping (Dissecting?) (rt) 128
Case 53 Semifusiform Pointing Toward the Approach
(1t) . . . . . . . . . . . . . . . . . . . 130 General Considerations 185
Case 54 Ring Clip for Preservation of a Perforator (1t) 132
Case 55 Large Fusiform Aneurysm with Three Ring 1 Anterior Skull Base Meningioma 188
Clips (1t) ................ 134
Case 79 Optic Nerve (rt) . . . . 188
Case 80 Tuberculum (1t) .... 190
Case 81 Tuberculum (Medial) (Bilateral) 192
IV Arteriovenous Malformation
Case 82 Tuberculum (rt) . . . . . . 194
Case 83 Tuberculum (rt): Metal Shield 196
General Considerations 136
2 Sphenoidal Ridge Meningioma 200
1 Temporal Lobe A VM 138
Case 84 Over Orbital Area (1t) 200
Case 56 Anterior Portion (1t) 138
Case 85 Anterior Temporal Fossa (rt) 202
Case 57 Anterior Portion with Aneurysm (1t) 140
Case 86 Huge Meningioma (rt) 204
Case 58 Posterior Portion (1t) 142
2 Central Area A VM 144 3 Intraventricular Meningioma 206
Case 59 Precentral: Small Residual (rt) 144 Case 87 In Trigonum (rt and It) 206
Case 60 Close to Broca Area (1t) . . . 146
Case 61 Under Broca Area (It) (Parasylvian Fissure) 148
4 Parasagittal and Falx Meningioma . . . . 208
Case 62 Large A VM (1t) ...... . 150
Case 88 Anterior Parasagittal Sinus (Bilateral) 208
Case 63 Large A VM: Breakthrough (rt) 152
Case 64 Large AVM: Breakthrough (rt) 154 Case 89 Unilateral Falx (rt) 210
Case 90 Bilateral Falx (rt) ....... . 212
3 Interhemispheric A VM . . . . . . . 156
Case 65 Anterior Portion (rt) . . . . . 156 5 Tentorial and Posterior Skull Base Meningioma 214
Case 66 Anterior Portion: Residual Nidus (rt) 158 General Considerations . . . . . . . . . . . . 214
4 Intraventricular AVM 160 Case 91 Anterior Tentorium (1t) . . . . . . . . 216
Case 92 Medial Tentorium and Clivus: Involvement of
General Considerations . 160
Vth Nerve (rt) . . . . . . . . . . . . 218
Case 67 Anterior Portion of the Ventricle (1t) 160 Case 93 Medial Tentorium and Clivus: Drilling off
Case 68 Posterior Portion of the Ventricle (1t) 162 Pyramid (rt) . . . . . . . . . . 220
Case 94 Medial Tentorium: Combined with
5 A VM in the Basal Ganglia 164
Suboccipital Approaches (rt) . . . 222
Case 69 Feeding from Posterior Communicating Artery Case 95 Large Medial Tentorium: Sacrifice of
(rt) . . . . . . . . . . . . . . . 164 Posterior Choroidal Artery (1t) . . . 224
Case 70 Feeding from ¥1, Al, and PCA (1t) 166 Case 96 Bilateral Occipital Lobes: Visual Cortex (rt) 226
Case 97 Posterior Tentorium (rt) 228
6 A VM Around the Tentorial Edge . . . 168
Case 98 Posterior Tentorium (1t) 230
Case 71 Above Quadrigeminal Plate (rt) 168 Case 99 Lateral Pyramid (1t) 232
Case 72 On Lateral Pons (1t) ..... 170 Case 100 Pyramid (rt) 234
Contents IX
VI Neurinoma and Other Brain Tumors 4 Glioma ..... . 248
General Considerations 248
1 Acoustic Neurinoma . 237
Case 103 Gliomas in the Thalamus and Adjacent
Regions 249
2 Trigeminal Neurinoma .... 244
Case 104 Optic Glioma 255
Case 101 Subtemporal Approach (rt) 244
References 259
3 Epidermoid Tumor . . . . . . . 246
Case 102 Cerebellopontine Angle (1t) 246 Subject Index 271
Abbreviations _______________________
XI
I Olfactory nerve p com Posterior communicating artery
II Optic nerve PICA Posterior inferior cerebellar artery
III Oculomotor nerve SCA Superior cerebellar artery
IV Trochlear nerve VA Vertebral artery
V Trigeminal nerve
VI Abducens nerve
VII Facial nerve
VIII Acoustic nerve Explanation of X-rays:
IX Glossopharyngeal nerve Axial CT scans show the right hemisphere on the right while
X Vagus nerve in coronal scans the right hemisphere is on the left. Abbrevia
XI Accessory nerve tions: preop, preoperative; postop, postoperative; lat, lateral
XII Hypoglossal nerve view; AP, anteroposterior view; CAG, carotid arterial angio
A Anterior cerebral artery gram; VAG, vertebral arterial angiogram.
Ai Proximal portion of the anterior cerebral artery
A2,3 Distal anterior cerebral artery Addresses of the Companies Supplying the Instruments
a ch Anterior choroidal artery
a com Anterior communicating artery Mizuho Ikakogyo Co., Ltd. (floating chair, operating table,
AICA Anterior inferior cerebellar artery instrument table, multipurpose head frame, tapered self
An Aneurysm retaining retractor, aneurysm clip, balanced suction, ta
B Basilar artery pered brain retractor, hook, and silver dissector): Hongo
C Carotid artery 3-29-10, Bunkyo, Tokyo, Japan.
Mi Proximal middle cerebral artery Nagashima Ika Co., Ltd. (operating microscope): Hongo
M2,3 Distal middle cerebral artery 5-24-1, Bunkyo, Tokyo, Japan.
MCA Middle cerebral artery Chiyoda Seisakujo Co. (microscope sterilizer): Koshoku, Na
Pi Proximal posterior cerebral artery gano, Japan
P2, 3 Distal posterior cerebral artery Nihon Kohden (facial movement monitor): Asahi 2-11-34,
PCA Posterior cerebral artery Matsumoto, Japan
1 Patient's Position
The position of the patient's head is of enormous importance
in the operation under an operating microscope. There are
two points to which particular attention must be paid. One
is the height of the patient's head, which should be above
the level of the heart in order to lower both venous and intra
cranial pressure. We make it a rule in the supine and prone
positions to elevate the upper half of the operating table by
about 30 degrees; raising the head more than 45 degrees runs
the risk of air embolism. The second point is that the main
operating procedure can and should be performed with the
microscope at a constant perpendicular visual axis by rotating
and/or tilting the patient's head. Working under a microscope
at an oblique angle for a long period is very tiring. Intraopera
tive correction of the head position to either side can be easily
done by rotating the head frame or tilting the operating table
sideways. However, it is difficult to correct the degree of flex
ion or extension of the head once surgery starts, and it is
therefore important to position the head properly in the verti
cal axis prior to surgery: the chin up or down in the supine
position, and the vertex up or down in the lateral position
(Figs. 1-1 and 1-2).
a
30± 5°
B A
-/
Fig. 1-1. Usual positioning of a patient. The upper portion of the
operating table is elevated 30 ± 5 degrees
Fig. 1-2. a Importance of patient's head: chin up or down. b In order
to see the base of the skull, the surgeon often has to change the
observation angle from A to B during surgery. When looking through
the microscope at angle A the eye-piece can be changed to a straight
type, but when observation from B is necessary the surgeon has to
take up a very awkward position as if he is looking at his own
stomach. In this case he can either move to the side or lower the
b
patient's head, or use a rectangular eye-piece if one is available
2 General Considerations
2 Skin Incision and Bone Flap uously for more than 10 min, the retractor should be moved
to another part of the cortical surface or released for a few
The skin incisions for different procedures have been discussed minutes. Such intermittent retraction is especially important
by many authors. I would just add here that we should when in operations on elderly patients and around critical areas
ever possible preserve the superficial extracranial arteries be such as the pons and medulla. The force and distance of re
cause bypass surgery between extra- and intracranial arteries traction are of course of similar importance. It is better to
may be necessary later in rare cases. The smaller the skin use two or three tapered brain retractors than an ordinary
incision and bone flap are, the shorter will the operating time non-tapered one with a tip wider than 8 mm. The surgeon
be. We should avoid making an unnecessarily large bone flap, must not forget to feel the consistency of the brain with his
though it is true that an intraoperative problem such as sudden fingers while fixing a brain retractor to the self-retaining re
brain edema will be more severe with a smaller craniotomy. tractor. When some hardness is felt through the retractor,
When approaching the skull base, it is very important that local brain edema is likely to appear postoperatively. The sur
the bone edge of the lateral side be removed as far as possible, geon has to learn to judge the safety range of retraction with
and the lateral extent of the craniotomy should be the longer. his fingers.
3 Retraction of the Brain 4 Preservation of Bridging Veins
Reduction of brain volume and gentle retraction of the brain I t is clear that preservation of a big vein can improve operative
are two important tactics. Administration of diuretics such morbidity especially in those cases where excessive brain re
as Mannitol, drainage of cerebrospinal fluid and hyperventila traction is required in combination with preexisting edema
tion are commonly used techniques which it is unnecessary or where the vein is draining an arteriovenous malformation.
to describe here. When the patient is elderly, there is usually We have used a method for preserving large bridging veins
plenty of space in the operating field even before brain retrac intraoperatively by stripping them from the cortex. After an
tion because the brain tends to be atrophic. Here, however, ordinary craniotomy and dural opening, and before starting
there is a particular danger of postoperative complications: brain retraction, the arachnoid and the cortex around a big
the brain of an elderly patient is hard and inelastic, so that bridging vein are dissected free for a length of 10 to 20 mm
even minimal brain retraction may result in postoperative distally (to the brain side) from the cortical edge. The length
brain edema, contusion, or intracerebral hematoma. The brain of stripped vein depends upon the width of brain retraction
of a young patient, in contrast, is usually very tight at the necessary for the subsequent procedure. Enough subarachnoid
beginning of the operation but gradually becomes slack thanks space is thus obtained, and the portion of the vein close to
to its elasticity, and generally tolerates stronger retraction the sinus could easily be stripped merely by dissecting the
well. The importance of gentle retraction increases with the arachnoid. However, the distal portion of the vein usually
age of the patient. Intermittent retraction using tapered brain remains tightly adherent to the arachnoid. Therefore, it is
retractors is recommended. usually safer to avoid injury to the vein wall by sucking the
Beside specific techniques such as dissection around an aneu smallest possible portion of the cortex, if it is not a critical
rysm and preservation of the facial nerve in acoustic neurin area such as a motor strip, and small tributaries of the vein
oma surgery, gentle yet adequate retraction of the brain is are occasionally sacrificed if necessary. Retraction of the brain
the most decisive general factor in minimizing postoperative slightly distant from the vein then makes visualization of a
complications. When the brain has to be retracted contin- deep-seated lesion possible without sacrificing the vessel
(Fig. 1-3).
Fig. 1-3. Preservation of bridging veins
II Instrumentation _____________________
3
J Operating Microscope edge or other object. (3) Rotation and tilting of the microscope
body can be performed easily and quickly. (4) Vertical shifting
The operating microscope is one of the most important instru can be done at two different speeds: fast and slow. (5) Acces
ments in modern neurosurgery. The history and technical as sory systems can be implemented easily when needed.
pects of the microscope have been discussed in many papers; Today each surgical speciality, such as ophthalmology, oto
here I would just briefly stress five important properties which logy, or orthopedics, has a different type of operating micro
the instrument must possess for neurosurgical application: scope built to fit the requirements of its own field. An operat
(1) The objects can be seen clearly and sharply through the ing microscope designed specifically for neurosurgical pur
lens system. (2) Illumination is strong and the illuminated poses is no less necessary. Fifteen years ago I designed an
field wide. Multiple sources of illumination are especially use operating microscope, type I, with two stereoscopic assistant
ful in neurosurgical applications because one beam may some scopes. A stereoscopic view is essential for an assistant sur
times be obstructed in a deep and narrow field by a bone geon who wants not only to gain the same experience as the
Fig. 11-1. Operating microscope Nagashima Ty
pe III; with pedal-controlled X-Y shifter and elec
tromagnetic suspension lock and a pair of stereo
scopic assistant microscopes
Fig. 11-2. Operating microscope Nagashima Ty
pe IV; with pedal-controlled X -Y shifter and elec
tromagnetic suspension lock. Upper: A usual as
sembly with a pair of stereoscopic assistant micro
scopes. Lower: Set-up of beam splitter for a nar
row operating field such as in transsphenoidal pi
tuitary surgery