Multiple Cerebral Aneurysms
Imagine a balloon stretched to the utmost and ready to burst. Brain blood vessels develop these little balloons called aneurysms. Unfortunately many of these do rupture and the result is a very sick patient. Coma and death may follow. Surgery of intracranial aneurysms is very delicate. If the aneurysm ruptures intra-operatively, death from the ensuing hemorrhage is possible. It’s technically demanding because there can be no error. This is “really brain surgery.” The anatomy is familiar but disorienting. The surgery is done upside down and sideways. The images demonstrate the exposure of the brain, blood vessels, nerves, and aneurysms. I thought I could run the operative video, but no. To the uninitiated, this was a particular technical challenge because of the presence of two aneurysms positioned on right and left brain vessels.
Yes, there were two, one on the right and one on the left. ‘Clipping’ both aneurysms and across the base of the brain is not commonly done. But it worked perfectly in this case. The patient had had a subarachnoid hemorrhage about a year ago. At that time, as is often seen, mirror aneurysms (multiple) were seen. Hidden but seen in retrospect was another right-sided aneurysm. The right posterior communicating (pcomm) aneurysm was repaired a year ago. The patient made a good recovery. She now has a left pcomm aneurysm and a right superior hypophyseal aneurysm. The images show the pcomm and then hypophyseal aneurysms clipped. The field of view under the operating microscope is about the size of a thumbnail. You could not do this without high magnification and very strong light. The first frame shows the olfactory (smell) nerve on the right leading to the optic nerve (vision) and the carotid artery is in the left corner. The next frame shows the optic nerve, carotid artery, aneurysm, and third nerve (movement of the eye). In the frame that follows the clip is applied to obliterate the aneurysm. It’s titanium and permanent. It spares and preserves the normal brain vessels so as to avoid a stroke from the operation. The next two frames show the second aneurysm on the right side. The left optic nerve, optic chiasm, right optic nerve, and carotid artery/aneurysm are seen. In the last frame the second aneurysm is clipped. The images are screen captures. It is a happy ending for the patient.