24 Microsurgery for Ruptured Aneurysms

Brian M. Howard and Daniel L. Barrow

Abstract

Aneurysmal subarachnoid hemorrhage is a potentially neurologically devastating and often fatal disease. Dramatic improvements in morbidity have been made over the past several decades as a consequence of improved microsurgical technique, endovascular therapy, and dedicated neurocritical care management. As the volume of microsurgically treated cases of ruptured intracranial aneurysms declines, current and future neurosurgical trainees and young neurosurgeons will need to make a concerted effort to hone their skills to assure that microsurgery remains a safe and viable option for patients as not all aneurysms are amenable to endovascular therapy. A craniotomy that most directly approaches the ruptured aneurysm while providing a wide surgical view is recommended for ease of clipping and to manage intraoperative complications. A well-thought-out clipping strategy is required prior to entering the operating room to assure operative efficiency, while adaptability is necessary as the surgical situation dictates. A parsimonious clipping strategy is typically best, but the shear array of aneurysm clips allows for tremendous versatility in clipping, particularly for complicated lesions that involve branch vessels, are adherent to en passage vessels, or involve a large circumference of the parent artery. Calmness under pressure is imperative in managing intraoperative complications such as aneurysm rupture.

Key words

subarachnoid hemorrhage - aneurysm - microsurgery

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