Basilar approaches Azam Basheer MD 9-2-14
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Transcript of Basilar approaches Azam Basheer MD 9-2-14
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Azam Basheer MDHenry Ford Neurosurgery
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Introduction
- Posterior circulation aneurysm ~10-15% of all aneurysms (basilar apex > SCA > PICA)
- First surgical clipping described by Gillingham in 1958 and Drake in 1961
- Both surgeons used a subtemporal approach with modest success
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Arises from the confluence of the two VA's at the pontomedullary junction
Ascends in the central gutter (sulcus basilaris)
Divides into PCA's and SCA's just inferior to the pituitary stalk.
BA Anatomy
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Thalamoperforators
Perforator Origins: basilar trunk, proximal P1, P-comm
Oculomotor nerve passes between PCA and SCA
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Interpeduncular Fossa
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Interpeduncular Fossa Boundaries
- Anterior: clivus and posterior clinoid processes
- Lateral: mesial aspects of the temporal lobes and tentorial edges
- Posterior: the cerebral peduncles
- Superior: mamillary bodies and posterior perforated
substance
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Relative indications for surgery
1. Unfavorable coiling anatomy
2. Thick cistern clot?
3. Symptoms attributable to brainstem compression (Giant aneurysms)
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Choosing the Right Surgery
① obtain the shortest trajectory to the lesion
② Adequate bone removal for minimal brain retraction
③ Skeletonization & protection of CN and vascular structure
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selection of surgical approach based on location
Site of Aneurysm Skull base Approach
Vertebral artery Far-lateral
Low Basilar Far-lateral
Midbasilar artery Petrosal,Subtemporal?
High basilar artery Pterional +/- OZ transyslvian
Subtemporal
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Basilar Apex
Two pure approaches
1. Trans-sylvian approach +/- Modifcations
2. Subtemporal approach
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Subtemporal Approach
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Trans-Sylvian Approach
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Trans-sylvian + OZ approach
More Superio-medial
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Trans-sylvian Approach
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Trans-sylvian approach
Assets Liabilities
• familiar
• prox. control
• exposure of both P1
• wide exposure
• Less temp. lobe
retraction than subtemporal
approach
• “Low” bifurcation BA
• Poor visualization of
peroforators
• ant. or post. directed
aneurysm
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Trans-sylvian approach
“low” bifurcation
Excellent visualization for aneurysms necks at the level between the midsellar depth and a line 1 cm superior
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Surgical Technique
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supine with head turned 45 degrees and slightly extended
Positioning is Key
Malar eminence
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zygomatic root 1cm ant to tragus, behind hair line towards midline
Incision
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Keyhole, above the zygoma, along the posterior temporal line, midfrontal
Temporalis muscle retracted down
Craniotomy
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Sphenoid ridge resection
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Ant. and Post. Clinoid Processes Resection
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Cutting arachnoid adhesions along
the middle fossa floor frees the
inferior temp lobe
Opening the Dura and Splitting The Fissure
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Divide the temporopolar vein to untether the anterior temporal lobe
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EVD placed intraoperatively
Paine's point
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Open the cisterns
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Anatomic triangles
providing access to the
basilar bifurcation:
1 optic-carotid triangle
2 carotid-oculomotor triangle
3 supracarotid triangle
The carotid-oculomotor
triangle is the one used most
commonly for basilar bifurcation
aneurysms.
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Identify the Pcomm and CN III
Open the membrane of Liliequist along CN III
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Liliequist’s membrane
CN III
PComm
Forms a “curtain” for the interpeduncular cistern and the roof of the prepontine
cistern
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Stay on inf. surf. of Pcomm to avoid injury to the
thalamoperforaters
Follow Pcomm to P1-P2 junction
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+/- Sacrficing the PComm
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Ensure Thalamoperforaters are free
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SUMMARY
Sylvian dissection: freeing of the frontal and temporal lobe
Open the cisterns
Open the membrane of Liliequist along CN III
Dissect along the Pcomm until P1 is seen and then follow to BA
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Subtemporal Approach
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Subtemporal approach
transsylvian app.
- below the middle depth of the
sella turcica
- posterior projection
- allows to dissect the perforators
of the posterior wall of aneurysm
- large aneurysm
right-sided approach : left III nerve palsy, right hemiparesis
left-side approach
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Subtemporal approach
Assest Liabilities
• prox. control
• dissection of perforators
• tentorial division widens exposure
• Good visualization of clip
• ant. or post. directed
aneurysm
• narrow field
• contralat. P1 control
• temporal lobe injury
• CN III palsy
• bleeding control
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Skin incision
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Craniotomy
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Biting off temporal bone
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Dural opening
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Lifting up temporal lobe
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Stitching up tentorium
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Vs. Cutting the tentorium
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Releasing arachnoid adhesions
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Checking for perforators
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Clip application
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Clip application