Intracranial Aneurysm Surgery: Basic Principles and Techniques

217 Pages·2011·7.9 MB·English

by  Duke Samson

Intracranial Aneurysm Surgery:
Basic Principles and Techniques

Intracranial Aneurysm Surgery:
Basic Principles and Techniques
Duke S. Samson, MD
Lois C. A. and Darwin E. Smith Distinguished Chairman in Neurological Surgery
Kimberly-Clark Distinguished Chairman in Mobility Research
Professor and Chairman
Department of Neurological Surgery
University of Texas–Southwestern Medical School
Dallas, Texas
H. Hunt Batjer, MD, FACS
Michael J. Marchese Professor of Neurosurgery
Professor and Chairman
Department of Neurological Surgery
Northwestern University Feinberg School of Medicine
Chicago, Illinois
Jonathan White, MD, FACS
Birsner Family Professorship in Neurological Surgery
Associate Professor and Program Director
Department of Neurological Surgery and Radiology
University of Texas–Southwestern Medical School
Dallas, Texas
J. Talmadge Trammell, MD
Neurosurgery Associates of West Texas
Hendrick Medical Center
Abilene, Texas
Christopher S. Eddleman, MD, PhD
Department of Neurological Surgery and Radiology
University of Texas–Southwestern Medical School
Dallas, Texas
Thieme
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5 4 3 2 1
ISBN 978-1-60406-693-7
Contents
Preface.................................................................................................................vii
Acknowledgments.............................................................................................ix
Abbreviations......................................................................................................xi
1 .Operating.Room.Considerations:.Equipment,.Setup,.
and.Culture...................................................................................................1
2 The.Evolution.of.the.Intracranial.Aneurysm.Surgeon......................8
3 .Aneurysms.of.the.Internal.Carotid.Artery.at.the.
Origins.of.the.Posterior.Communicating.and.Anterior..
Choroidal.Arteries.....................................................................................15
4 Aneurysms.of.the.Proximal.Internal.Carotid.Artery.......................33
5 Aneurysms.of.the.Internal.Carotid.Artery.Bifurcation...................53
6 Aneurysms.of.the.Middle.Cerebral.Artery.........................................61
7 Aneurysms.of.the.Anterior.Communicating.Artery........................88
8 Aneurysms.of.the.Distal.Anterior.Cerebral.Artery........................110
9 .Aneurysms.of.the.Vertebral.Artery.at.the.Origin.of.
the.Posterior-Inferior.Cerebellar.Artery..........................................117
10 Aneurysms.of.the.Vertebrobasilar.Junction...................................136
11 Aneurysms.of.the.Proximal.Basilar.Artery.....................................146
12 Aneurysms.of.the.Basilar.Apex...........................................................159
13 Very.Large.and.Giant.Aneurysms......................................................181
14 Surgical.Management.of.Previously.Coiled.Aneurysms..............189
Index..................................................................................................................197
v

Preface
In 1988 Hunt Batjer and I began to write a short text on basic operative tech-
niques and approaches used in intracranial aneurysm surgery. The impetus for
this shared effort was our mutual belief that there were no reliable, straightfor-
ward, “cut-on-the-dotted-line” sources available to help young, would-be aneu-
rysm surgeons learn the tools of their trade. By that point in our own learning
curves, we had individually and collectively committed enough serious mistakes
to make us firm believers in the value of an “operation by the numbers” philoso-
phy whenever possible—all that was missing was the instruction manual.
After the routine series of false starts (and a couple of divorces), Intracra-
nial Aneurysm Surgery Techniques was published by Futura in 1990. For bet-
ter or worse, we resisted our first impulse to title the book Aneurysm Surgery
for Dummies, although when we later mentioned that lost opportunity to Dr.
Charles Drake, he paused for a second then replied, “For . . . and by, eh?”
We all laughed so hard that Dr. Drake spilled his scotch.
Over the next several years, our text became gratifyingly popular with its in-
tended audience, and Hunt and I both were the proud recipients of late night calls
and quick thank-yous scribbled on progress note paper from surgeons who be-
lieved “the little aneurysm book” had helped them find an elusive contra-lateral
A1 segment or finally close a broad-necked aneurysm that just refused to die.
Techniques went out of print in 1999. Subsequently, we resisted requests to
reissue or revise the book, in part out of pure laziness, in part because of the
large number of recently published volumes dedicated to cerebrovascular dis-
ease, and in part due to the increasing importance of endovascular techniques
in the management of intracranial aneurysms.
Hunt and I contributed to many of those expansive textbooks and believed
that, taken as a group, they offered more than adequate explanations of every
surgical technique known to man, especially if the young surgeon was willing
to pick and choose judiciously among the offerings. Additionally, faced with the
rapid evolution of endovascular techniques, neither of us, frankly, wanted to
invest large amounts of time and effort in the tedious description of technical
exercises that, in the not-too-distant future, might well become as arcane as the
art of pneumo-encephalography.
So what changed? All of us have other demands on our time, publishers
continue to grind out impressive tomes devoted to operative techniques, and
healthcare think tanks, such as the Advisory Group, predict that endovascular
techniques, generally in the hands of neurosurgeons, will account for some-
where between 60–80 percent of all aneurysm treatment by 2020. In light of all
vii
viii Preface
this competition, what justifies a reexamination of the fundamental microsur-
gical techniques involved in aneurysm surgery?
First, even in the face of rapid development and impressive improvements
in endovascular technology and techniques, there remain a large number of in-
tracranial aneurysms for which microvascular surgery remains either the only
or the preferable management option. Additionally, the complications of en-
dovascular treatment have generated a unique subset of aneurysms requiring
special surgical skills. Preparation to meet the challenges raised by all of these
lesions begins with assimilation of basic aneurysm surgical techniques and the
development of a conceptual framework for their use.
Second, we still believe the most reliable training ground for excellent mi-
crosurgical technique remains cerebrovascular disease in general and aneu-
rysm surgery in specific. Realistically, if a surgeon has the requisite skills to
deal successfully with the vagaries of aneurysm surgery, he or she has at least
the technical abilities to deal with the breadth of neurosurgical pathology. Fur-
thermore, despite the wide-spread availability of lengthy texts that address all
aspects of intracranial vascular pathologies, there seems to remain a persis-
tent demand, especially among young practioners, for nitty-gritty, “first-you-
do-this-and-then-you-do-that” technical advice presented in a consistent,
straight-forward, didactic format.
Third, over the past two decades, surgeons at our institution have treated
almost 3,000 additional aneurysm patients, an experience that has significantly
changed the technical nuts-and-bolts of my own practice. We don’t operate or
teach using exactly the same principles as we did in 1989; I think (hope) that
some of these changes help to make aneurysm surgery safer and simpler, and
we’d like to share them with the next generation of cerebrovascular surgeons.
The volume is organized with general operating room principles first, fol-
lowed by a sequential discussion of aneurysms of the carotid, middle cerebral,
and anterior cerebral arteries. We then move to the posterior fossa, beginning
proximally with lesions of the vertebral artery, then moving distally to the basi-
lar apex. The book concludes with a discussion of the concepts and techniques
we’ve found helpful in the surgical management of very large and giant aneu-
rysms and a review of the unique problems posed by previously-coiled and /or
stented aneurysms.
The five authors want to emphasize that the approaches, techniques, and
tricks outlined in this brief volume represent only a single surgical philosophy
in aneurysm management. As noted, all of us are aware of and in awe of the nu-
merous other technical approaches described by the two master aneurysm sur-
geons, Drs. Drake and Yasargil, as well as more recent but equally inspired works
by gifted vascular surgeons such as Bob Spetzler, Roberto Heros, Dick Winn, Art
Day, and Mike Lawton. With appreciation—but no apologies—to these folks, this
book is a “how-we-do-it-here-in-Dallas-and-Chicago” manual that is written for
the express purpose of helping young aneurysm surgeons learn their craft.
Duke Samson
Dallas, Texas
Acknowledgments
As I’ve said many times, Hunt’s move to Northwestern in 1996 dramatically
lowered the mortality rates at both institutions, but he naturally remains a ma-
jor part of the authorship of this “how to do it” manual. Tom Kopitnik, Bob Re-
plogle, Mike Horowitz, and Babu Welch, all of whom have shared the burden of
aneurysm surgery at Southwestern since 1990, have made major contributions
to the thought process behind this text, and I sincerely appreciate their support
and friendship.
One of my coauthors this time out is another University of Texas–South-
western cerebrovascular disciple, Jonathan White, who actually bats from both
sides of the vessel. After operating on over 600 aneurysms in his first five years
of practice, Jon has now completed his formal endovascular training. He, and
surgeons like him, are the bright future of our specialty, and I’m grateful for his
unique perspective in this effort.
After some rumination, Hunt, Jon, and I felt that insights from another fresh
viewpoint would offer a potentially important flavor to this educational en-
deavor. In consequence, we convinced an outstanding young neurosurgeon,
Talmadge Trammell, to add his perspective in helping us translate our some-
times obtuse thought processes into legible diction. “T”—as he’s known far and
wide—has the unique viewpoint that comes only with the experience of carry-
ing the gospel from the mother ship to a far planet. We are truly appreciative
of his help.
Finally, we found the assistance of another dual-trained young neurosur-
geon—Christopher Eddleman—to be an enormous help in bringing this project
to successful completion. Chris, who has suffered under the tutelage of both
senior authors, has not only patiently refined all of our initial offerings, but also
provided valuable insights in his own chapter, “The Evolution of the Intracranial
Aneurysm Surgeon.”
The heart of this book is composed of illustrations that translate our bare-
bones narrative into eloquent, anatomical fact. For this beautiful body of work,
we’re indebted to Suzanne Truex who devoted two years of her professional
life to this effort and, consequently, has come to think of the basal cisterns as a
second home.
No two individuals have contributed as much to the surgical management
of intracranial aneurysms as Dr. Charles Drake and Dr. M. Gazi Yasargil. Their
work, accomplishments, and friendship form the inspiration for this book.
Finally, one brief expression of personal gratitude to my wife, Dr. Patricia
Bergen, and our fine sons, Daniel and Gabriel.
ix