Anda di halaman 1dari 7

Gonzales, Analysa M

02/24/10
Aneurysm Surgeries

According to a study done in 2008, approximately eight to ten million people in the

United States have brain aneurysms. Up to three percent of those are likely to face bleeding. A

brain or cerebral aneurysm is a serious medical condition associated with the malformation of the

elastic layer of a blood vessel in the brain. This defect in the wall allows ballooning in the vessel

wall when pressure rises which can lead to the blood vessel rupturing.

Detection, unfortunately, does not typically occur until after a

blood vessel has ruptured. Doctors often use cerebral angiography,

injecting a dye into the circulatory system, in order to provide a

roadmap of blood circulation in the brain. This reveals unusual

expansions in the walls of blood vessels when X-rayed.


http://neurosurgeononcall.com/images/aneurysms

Emergency treatment is necessary for individuals who experience a rupturing blood

vessel. Currently, there are two primary options for the treatment of a brain aneurysm: clipping

and coiling. The optimal choice of treatment depends on the location and size of the particular

aneurysm.

Surgical clipping is a procedure in which the aneurysm is safely isolated from normal

flowing blood circulation. Before the surgery, swift preparation is necessary for both the

surgeons and the patient. Tests such as blood typing, urine and sodium output, and blood counts

occur for those whose aneurysms have not yet ruptured. An assessment of the patient’s airway,

breathing, circulation, and deficit (any particular health issue) is also made. Keeping the patient’s

blood pressure at a healthy and stable level is extremely important; most doctors will have the

patient placed in a quiet and calm environment before the procedure in addition to taking

medication or being sedated to reduce blood pressure. Within about six hours before the surgery,
Gonzales, Analysa M
02/24/10
Aneurysm Surgeries

food and drink will no longer be permissible. In cases where a rupture has already taken place,

many will immediately take to the operating room after blood pressure stabilization. Swiftly, an

intravenous line (IV) in placed in the patient’s arm just before the procedure is set to begin.

The surgery generally lasts anywhere from three to five hours. In all forms of aneurysm

clipping, the patient is first given general anesthesia. Once asleep, the surgical team adjusts the

position of the patient and places their head on a holding device used to hold the skull in position

during surgery. The area of incision is then prepared by shaving (usually behind the hairline) that

particular area. Hairy sparing techniques do exist for those who are concerned. Occasionally,

some patients have a lumbar drain installed in their lower back to remove any cerebrospinal fluid

that may interfere with brain relaxation during surgery. A drug may be administered for the same

purpose.

The second step requires the neurosurgeon to perform a craniotomy. First, the skin

incision exposes the skull, creating a flap. This flap of skin and muscle is then lifted from the

bone and folded neatly back to allow a clear view of the patient’s

skull. Next, small holes known as burr holes are made in the skull

using a drill. A craniotome is then inserted within the burr holes

and used to cut a window of bone from the cranium which exposes

the dura matter, the outermost layer of the brain. Safely stored

away, the flap of bone will no longer be needed until the end of the

procedure.

Again, a folding occurs with the dura in order to fully expose the brain. A space between

the brain and the surrounding skull is necessary, so the surgeon uses retractors while operating
Gonzales, Analysa M
02/24/10
Aneurysm Surgeries

under a microscope to gently ply a space. The surgeon then proceeds to locate the artery in

question and follows it to the aneurysm. Once located, blood flow in and out of the aneurysm

must be controlled; usually that control may be obtained by managing the carotid artery in the

neck. A safety clip to stop bleeding is kept nearby in case of accidental rupturing.

Inserting the actual clip involves using a clip applier to hold the clip open until released,

which will pinch and therefore isolate the aneurysm from the parent artery. A surgeon may use

multiple clips if necessary. In figure 1 below, a common clipping of the neck of the aneurysm,

also known as direct clipping, is shown. However, clipping the neck is not the only means of

clipping that a surgeon may use. The placement of the clip depends on the location and the size

of the aneurysm, as well as the particular affected

artery. Figure 2, for example, shows the trapping of

an aneurysm. In this form of clipping, blood flow 1 2 3


1
leading into the affected area of the artery is completely cut off. This procedure is often
1
classified as a surgery of its own, also known as occlusion, which is followed by a bypass. In the

bypass, surgeons surgically graft a smaller blood vessel to the artery, therefore rerouting the

circulation of blood away from the aneurysm. Both forms of clipping follow the same basic

procedures.

Of course, the surgeon cannot simply conclude the clip is in perfect place and will do its

job, so inspection immediately afterwards is imperative. The clip must not be cutting off or

narrowing the parent artery or any other arteries, including any nearby perforators. A hole in the

aneurysm is then made with a needle in order to insure that blood flow has been completely cut

off.
Gonzales, Analysa M
02/24/10
Aneurysm Surgeries

The last step of the surgery occurs with replacing the coverings of the brain. First, the

retractors used previously are removed. Using sutures, the surgeon then closes the dura. The

bone flap set aside in the beginning of the operation is replaced and secured to the skull by using

titanium plates and screws. The flap of skin is then sutured back together over the newly secured

bone flap, and a soft adhesive is used over the incision made.

Upon the completion of surgery, the patient will be taken to the recovery room, where

their vital signs will be carefully monitored as they awake from the anesthesia. Once awake, they

will often be transferred to a neuroscience intensive care unit for more observation. The most

common immediate side-effects of the operation include nausea and headaches; pain medication

will usually be administered. During the entirety of the recuperation and observation period, it is

important for a patient to remain in bed until the bleeding completely stops. Gradually, those in

charge of monitoring the patient will help them increase their activity level and monitor the

patient throughout the duration. After a few days, the patient will be released from the hospital;

unless their aneurysm ruptured, in which case they will be monitored extensively from anywhere

between two to three weeks. Observation is especially important for such patients, since they are

most likely to develop signs of vasospasm, a narrowing of an artery.

Even after the surgical procedures end, and they are released from the hospital, patients

should monitor any conditions that can contribute to another aneurysm, such as high blood

pressure. According to the Mayfield Clinic in Cincinnati, Ohio, “the possibility of having a

rebleed [relapse of bleeding in the affected area] increases to 35% within the first 14 days after

the first bleed.” Unfortunately, clipping is not always the best solution, as risks to some might

well outweigh the benefits.


Gonzales, Analysa M
02/24/10
Aneurysm Surgeries

For those individuals, there is a second option for treatment that does not require open

brain surgery. This treatment, commonly called coiling, is known as endovascular embolization.

As seen in figure 3 above, this alternative treatment involves a small

incision being made in the groin area. The doctor then uses a needle to

create a small hole in the femoral artery. A microcatheter is then

inserted into the artery and guided up into the brain’s blood vessels until it

reaches the aneurysm. The catheter www.medscape.com deposits soft platinum coils into the

space of the aneurysm, which conform to its irregular shape. Anywhere from five to seven coils

are usually required to completely pack the aneurysm. Once completely packed, the coil is

released by a low voltage current that causes the pusher wire to detach from the coil inserted into

the aneurysm.

The ultimate goal of endovascular embolization is the same as that of clipping: to prevent

blood flow into the aneurysm. The approach, however, is the true difference, as no artery

blocking occurs. Rather, the coils fill the aneurysm so that no blood may enter into the sac and

cause bleeding. Unlike clipping, embolization cannot repair arteries already injured.

The treatment is performed under general anesthesia, taking only a few hours; and

generally the patient must stay in the hospital for two nights of observation after the procedure.

The Neurosurgical Intensive Care Unit will monitor the patient during their rest period of

approximately eight hours. Most patients do need to return for follow up tests and observation to

insure the success of the procedure.

Unfortunately, for those individuals whose aneurysms rupture, many complications can

arise, including subarachnoid hemorrhage. The side effects can often leave them with a
Gonzales, Analysa M
02/24/10
Aneurysm Surgeries

permanent disability or lost function to some degree. Patients often need rehabilitative, speech,

and occupational therapy in order to regain any of the lost function they experience. Thought

aneurysms can be difficult to detect, it is highly important that tests be run if there is any reason

at all to believe that a problem may exist within the circulatory system of the brain. It is even

more imperative that such an individual seek immediate medical treatment.


Gonzales, Analysa M
02/24/10
Aneurysm Surgeries

Works Cited

Bethesda. "Brain Aneurysms." NINDS. Feb. 2010. Web. 24 Feb. 2010.


<http://www.ninds.nih.gov/disorders/cerebral_Aneurysm/detail_cerebra
l_aneurysm.htm>.

"Endovascular Embolization." How Stuff Works. 2010. Web. 24 Feb. 2010.


<http://healthguide.howstuffworks.com/endovascular-embolization-
dictionary.htm>.

Hanover. "Endovascular Enmbolization." The Brain Aneurysm Foundation.


2009. Web. 21 Feb. 2010.
<http://www.bafound.org/treatment/endovascular.php>.

Harrol, A. "Brain Aneurysms." 2006. Web. 24 Feb. 2010. <http://www.brain-


aneurysm.com/ba2.html>.

Mangiardi. "Brain Surgeries: Clipping." Brain Surgery. 2010. Web. 22 Feb.


2010. <http://www.brain-surgery.com/aneurysm.html>.

Mayfield. "Clipping." Mayfield Clinic, 2010. Web. 22 Feb. 2010.


<http://www.mayfieldclinic.com/PE-Clipping.htm>.

'ORlivedotcom' "Brain Aneurysms." YOUTUBE. 2010. Web. 21 Feb. 2010.


<http://www.youtube.com/watch?v=8sGsa5KFJCI>.

Utoronto. "Endovascular (Embolization) Treatment of Aneurysms." U of T.


Nov. 2009. Web. 24 Feb. 2010.
<http://brainavm.oci.utoronto.ca/malformations/embo_treat_aneurysm
_index.htm>.

Vyavhare, Amol. "Aneurysms." Articles Wave. Apr. 2008. Web. 22 Feb. 2010.
<http://www.articleswave.com/health-articles/brain-aneurysm.html>.

Anda mungkin juga menyukai