Pitfalls in aneurysm surgery in acute stages

Since the dawn of aneurysm surgery, many aneurysms present a more complex challenge. Large size, intimacy with critical perforator branches, deep location, atherosclerotic walls, ruptured aneurysms in the elderly and incorporation of afferent or efferent arteries in the dome represent factors that singly or in combination preclude safe clipping while high pressure circulation continues in the aneurysm. Despite the relative frequency of many class of aneurysms, there remains in the neurosurgical community some degree of confusion regarding the detailed anatomic features and the technical aspects of the treatment of these lesions in the acute stage. In our study of 1,433 cases, we have enumerated four aspects of the pitfalls in aneurysm surgery which should be considered when planning the operative approach to these lesions. These four aspects will be reviewed in relation to the aneurysm surgery: (1) inadequate pre-operative planning; (2) inappropriate response to unexpected premature rupture; (3) poor clipping techniques and clip selection; (4) unintentional occlusion or injury of perforating branches. This discussion will simply elaborate our own conceptual and microsurgical technical approach in dissecting the aneurysms. Minimal retraction was used during the whole surgical procedure. The intracranial brain tension was reduced through a ventricular tap for hydrocephalus or evacuation of hematoma prior to aneurysm surgery. A venous pathway was established for blood circulation. Sharp dissection, using our newly designed jet irrigation bipolar suction method was employed. Regarding the clipping of the aneurysm, we used the tentative clipping and the dome coagulation method thereby preventing the ischemic changes and shortening of the entire clipping procedure. Although the strategies, discussed represent simply our approach to this problem, the principles included have proven quite successful and have allowed safe and definitive treatment in the overwhelming majority of patients and also options to overcome the pitfalls in aneurysm surgery.