Abstract
Growth of a cerebral aneurysm may cause adhesion to surrounding structures. The procedure to detach a cerebral aneurysm from surrounding structure plays a crucial role in implementing an appropriate clipping strategy for aneurysmal surgery. Structures that adhere to the aneurysm can include major arteries, perforating arteries, veins, dura mater, brain tissue and clot. Adherent structures can thus be divided into two categories : vessels and other structures. Among frequently encountered situations, adhesion to vessels is one of the most problematic. In this case, fibrous adhesion shows characteristics of being tight at the margins, but loose in the center. In dissecting between the cerebral aneurysm and fibrous adhesion, making the most of this characteristic is important. First, dissect the loose adhesion in the center using jeweler's forceps to make space. Second, pinch the tight adhesion at the margin to emboss the fibrous adhesion. Finally, sharply incise the embossed fibrous adhesion with micro-scissors. Repeating these steps allows detachment of the adhesion with the aneurysm. Other structures such as adhered brain tissue, clots and dura mater may require complete exposure of the aneurysm to ascertain surrounding perforating arteries and cranial nerves. Utilizing a suction tube and brain retractor with appropriate pressure is essential for exposing the correct dissecting layer. In addition, retracting the brain, vessels, and sometimes the aneurysm itself is important to stabilize and enabling exposure of the correct layer. With a ruptured aneurysm, dissecting circumferentially while leaving the brain tissue and clot attached at the rupture site is important to avoid intraoperative rupture. In this article, we discuss and introduce practical methods for dissecting the structures surrounding cerebral aneurysms.
