微创拇指大小翼点入开颅未破裂前循环动脉瘤的手术夹子结扎
Summary
微创拇指大小的翼点入路开颅动脉瘤夹闭已经给我们的患者住院时间短以较低的成本比全国平均水平。
Abstract
微创手术方法为颅内动脉瘤夹闭可以减少住院时间，手术并发症，治疗费用长度，改善患者的预后。我们提出我们的经验，在一个大型三级脑血管中心进行的前循环动脉瘤微创翼点入路，并比较结果与来自全国住院样本（NIS）的年龄匹配的数据集。 2008年8月至2012年12月，患者≤55岁22选修瘤剪报由同一双奖学金训练有素的脑/神经外科血管内进行。 1例（4.5％）经历了短暂的术后并发症。 18 22例恢复为后续成像，并有经过22个月的平均持续时间没有复发。在NIS数据库2008至2010年进行搜索，也为年龄≤55岁的患者，取得了1,341住院的手术unrupt结扎夹被保险脑动脉瘤。逗留和住院费用使用微创拇指大小的翼点入路术住院长度在我们的机构几乎NIS的一半（停留时间：3.2比5.7天;住院费用：52779美元与101882美元）。微创拇指大小的翼点入路开颅允许未破裂小型和中型的前床突上循环动脉瘤良好的曝光。从键蛛网膜下腔水箱及恒定双手显微外科技术脑脊液引流避免需要拉钩可在牵开器站点造成挫伤，局部静脉梗塞，以及手术后的脑水肿。利用这套技术已经给我们的患者住院时间短以较低的成本比全国平均水平。
Introduction
手术结扎夹已经治疗颅内动脉瘤的中流砥柱，但最近已经由微创腔内技术主要是取代1,2临床试验，包括未破裂颅内动脉瘤的国际学习（ISUIA-1和ISUIA-2），以及国际蛛网膜下腔动脉瘤试验（ISAT）已证明低发病率和死亡率，住院时间长度缩短，并降低整体的费用，与血管内治疗相比手术夹子结扎3 – 5然而，血管内治疗后的较高动脉瘤的复发率，导致了检查的累积风险的患者相比，手术夹子结扎。3,4-外科治疗仍然是动脉瘤治疗的重要方式，特别是对于具有形貌可能难以治疗与血管内装置的前循环动脉瘤。
<p cl屁股="“jove_content”">不像在血管内设备的进步，在外科手术技术几进展最近已经作出。技术，使手术治疗创伤小已包括眶上开颅结合眉切口前循环动脉瘤“手术retractorless”期间动脉瘤夹闭减少手术创伤对大脑6 – 8这些微创手术方法可减少住院的长度留，手术并发症，治疗费用，并改善患者的预后。9在这里，我们提出我们的经验，以微创的方法来使用在一个大型三级脑血管中心进行的前循环动脉瘤翼点入路未破裂颅内动脉瘤手术结扎夹和比较的结果与年龄从全国住院样本数据集相匹配（NIS ）。该手术技术进行审查，包括病人的准备，放松大脑，外侧裂解剖和闭合。术后护理和排放要求也将被概述。
Protocol
注：在执行此过程，获得所有必要的机构批准和患者同意。 1.手术技巧导致患者全身麻醉。 将桡动脉血压监测。 将病人在手术室表仰卧位。 后头部被夹入使用标准技术用于一个翼点开颅梅菲尔德头保持器，与同侧面朝上放置磁头30°-45°朝天花板，除了在该头被放置在60°的前 – 交通动脉瘤要允许跨纵裂更好的可视化。 定位颈部中线和翻译?…
Representative Results
目前，在我们的机构超过150个动脉瘤，每年处理。 2008年8月至2012年12月，采用对病人≤55岁supraclinoidal这个动脉瘤微创拇指大小的翼点入路开颅术22选修瘤剪报由同一双奖学金训练有素的脑血管/血管内，发达国家这种技术的神经外科医生（EMD进行）（ 表1）。这个年龄组被选择作为早期试验显示，手术治疗动脉瘤的患者高于此年龄结果比血管内治疗，因此，55岁以上少数患者用手术夹子…
Discussion
颅内动脉瘤的手术夹子结扎保持在治疗某些类型的动脉瘤的一个相关和重要的选项，尽管这个作用已被削弱，在过去几年中作为血管内技术变得更安全和更有效。血管内介入治疗已超过手术的脑动脉瘤，但血管内治疗后复发率较高，偶尔需要进行动脉瘤复发从血管内治疗失败后手术治疗，具体的形态使得血管内治疗的风险较高，需要放置支架，以及最近的一些文献回顾累计血管内治疗比手术治疗?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
The authors have no acknowledgments.
Materials
| Mayfield Infinity skull clamp | Integra | A-1114 | |
| Mayfield table attachment | Integra | A-1018 | |
| 4-French Fukishima suction tip | Integra | R-8986 | |
| Periosteal elevator (Langenbeck) | Codman | 65-1116 | |
| Metzenbaum scissors | Codman | 36-5023 | |
| Malis dissector, round angled | Codman | 80-1541 | |
| Penfield dissector, style 1 | Codman | 65-1015 | |
| Lempert bone rongeur | Codman | 19-1232 | |
| Malis Irrigation Module | Codman | Module 1000 | |
| Bovie monopolar electrocautery device | Codman | ||
| Insulated blade for electrocautery device | Covidien | E1455 | |
| Fish-hook retractors | Lone Star | 3350-8G | |
| Pneumatic drill | Medtronic | Midas Rex MR7 | |
| Side-cutting drill | Medtronic | F2/8TA23 | |
| Fluted legend match head tool | Medtronic | 10MH30 | |
| Surgical scalpel No. 10,11,15 | Bard-Parker | 0029064 (No.10), 0018291 (No.11), 0018043 (No.15) | |
| Intra-operative microscope with mouthpiece | Leica | ||
| Microscissors | V. Mueller | NL3785-034(st), NL3785-035(cvd) | |
| Rhoton dissector, #2 | V. Mueller | NL3785-002 | |
| Telfa strips | American Surgical | #80-09 (1/2×3), #80-04 (1/4×3) | |
| Aneurysm clip | Aesculap | ||
| Raney clip applier | Aesculap | FF012R | |
| Synthes Matrix metal plating system | Synthes | ||
| Braided absorbable surgical sutures (Vicyrl) | Ethicon | J790D (3-0), J743D (4-0) | |
| Braided nylon nonabsorbable surgical sutures (Nurolon) 4-0 | Ethicon | C584D | |
| Doppler System | Mizuho | 07-150-02 |
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Cite This Article
Deshaies, E. M., Villwock, M. R., Singla, A., Toshkezi, G., Padalino, D. J. Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms. J. Vis. Exp. (102), e51661, doi:10.3791/51661 (2015).