Intracranial aneurysm clamping surgery is a difficult and high-risk operation in neurosurgery, and whether aneurysm rupture can be prevented or treated during the operation is the key to the success of the operation.
I. Intraoperative rupture factors of intracranial aneurysm.
The trend of intracranial aneurysm surgical treatment advocates early or ultra-early, and the benefit of early surgery can prevent the aneurysm from bleeding again. However, as the aneurysm rupture is in a fragile state in the early stage of surgery, although the tissue repair and surrounding adhesions play a certain wrapping role over time. However, its repair and surrounding adhesions are poor in any case, and it is especially prone to intraoperative rupture.
1.The induction period of anesthesia makes the blood pressure rise; the head frame fixation causes the blood pressure to rise due to the patient’s pain.
2.Shock caused by skull drilling.
3.Sharp pressure changes caused by cutting the dura mater.
4.Excessive stretching of brain tissue.
5.When separating the aneurysm-carrying artery or aneurysm.
6.Removal of peri-aneurysmal hematoma.
7.Puncture of the neck of the aneurysm when the aneurysm is clamped.
8.The aneurysm clip cannot be separated from the aneurysm clamp smoothly.
II. Prevention of intraoperative aneurysm rupture.
Intracranial aneurysm surgery is usually performed under prepared conditions, and to prevent it during the surgery, it should be done
1. Adequate preparation should be made for the surgical procedure of aneurysm, and the operation must be performed under a microscope.
2. Require smooth anesthesia during surgery, especially when opening the dura and separating the aneurysm, require controlled pressure reduction, generally control the average arterial pressure down to 1/3 of the preoperative period, which can reduce the transmural pressure of the aneurysm.
3.Lower the brain pressure and fully dissect the brain pool so that the cerebrospinal fluid flows out automatically and the brain tissue retracts, while avoiding pulling the brain tissue to cause aneurysm rupture.
4.Avoid accidental injury. The aneurysm neck, aneurysm body, aneurysm-carrying artery and penetrating branch should be carefully and clearly identified under the microscope.
Before clamping, the proximal end of the aneurysm-carrying artery should be fully exposed and the temporary blocking space and distal clamping space should be prepared.
6.The risk of rupture of combined hematoma aneurysm is higher, so the peri-arterial hematoma should be carefully removed along the anatomical direction of the aneurysmal artery to reveal the aneurysmal artery. After clamping, the hematoma should be completely removed.
If the aneurysm neck separation is not ideal, the aneurysm-carrying artery can be temporarily blocked first, and then the temporary blocking clip can be removed after the aneurysm neck is separated and clamped.
8.The anatomical variation of anterior communicating aneurysm is more complicated, and there are often variant vessels, so both A1 segments must be exposed, especially the main A1 segment.
9.The aneurysm neck separation must be done properly, and the aneurysm clip should be placed only when it can be done, and no operation unrelated to this should be done, so that the aneurysm clip can be placed properly.
Emergency treatment of intraoperative rupture of aneurysm.
1.The operator must be calm and collected to avoid causing new injuries.
2, first of all, to control the bleeding, at this time, the brain pressure plate firmly can not be lifted, can be compressed by the assistant internal carotid artery, suction device to remove the blood, to maintain a clear surgical field. If the neck of the tumor can be clamped, it can be clamped directly. If clamping is difficult, temporary blocking clamps can be used to block the proximal and distal ends of the aneurysm-carrying artery respectively, and then separate the neck of the aneurysm and clamp it. Generally, the duration of temporary blocking clamps should not exceed 10 minutes. There are 4 cases in this group in which temporary blocking clips were used without sequelae.
3.The entire aneurysm neck of the ruptured aneurysm should be torn by suturing and wrapping the rupture. In this group, one case of aneurysm neck tear failed to be closed with silk suture, and finally the internal carotid artery was forced to be clamped. Fortunately, only mild hemiparesis of the contralateral limb was left after the operation.
In conclusion, it is best to prepare for rupture prevention during intracranial aneurysm surgery to avoid or reduce factors that may cause intraoperative rupture. In case of intraoperative rupture, we should be calm and steady to effectively control the bleeding and successfully clamp the aneurysm. To prevent postoperative cerebral vasospasm in ruptured aneurysms, local soaking with infusional cotton can be used, and postoperative raising of blood pressure, increasing blood volume and applying calcium antagonists can reduce brain damage caused by cerebral vasospasm.