Permanent Clipping
6 Permanent Clipping Clip Application Applying a permanent clip on an aneurysm neck is like landing an airplane, requiring just the right “yaw, pitch, and roll” (Fig. 6.1A). Pitch refers…
Subarachnoid Dissection
2 Subarachnoid Dissection The Subarachnoid Cisterns The subarachnoid space is the arena of aneurysm surgery because it houses the brain’s arteries and provides a navigable labyrinth to deep targets that…
Far-Lateral Approach
13 Far-Lateral Approach Position The far-lateral approach is also called the lateral suboccipital approach, the extreme lateral approach, and the extreme lateral inferior transcondylar exposure (ELITE). A modified park-bench or…
Orbitozygomatic Approach
11 Orbitozygomatic Approach Rationale and Indications The orbitozygomatic approach dramatically enhances the standard pterional craniotomy. When a patient’s head is rotated away from the aneurysm and extended, the superior and…
Pterional Approach
10 Pterional Approach Position The patient is positioned supine with a bolster under the shoulder ipsilateral to the aneurysm. The head is rotated 15 to 20 degrees away from the…
Anterior Interhemispheric Approach
12 Anterior Interhemispheric Approach Position, Incision, and Extracranial Dissection Pericallosal artery (PcaA) aneurysms originate from a right-or left-sided bifurcation of the anterior cerebral artery (ACA), but are midline aneurysms deep…
Brain Transgression
8 Brain Transgression Violation Vascular neurosurgery is a refined art. The dexterity, grace, and precision of a master neurosurgeon are awe-inspiring; the movement of microsurgical instruments among arteries and nerves…
Under the Microscope
1 Under the Microscope The Microscope The operating microscope is the neurosurgeon’s most important tool. It illuminates the operative field, magnifies anatomy, and gives constant visual feedback. Skillful dissection depends…
Vascular Control
4 Vascular Control Contingency Planning A reality of aneurysm surgery is that the technical skill and surgical experience do not eliminate the risk of intraoperative aneurysmal rupture. The dangerous combination…
Intraoperative Rupture
9 Intraoperative Rupture Ever-Present Danger Uncontrolled intraoperative bleeding is one of the most feared complications in neurosurgery. It has been said that uncontrolled bleeding is the one factor above all…
