Ultrasound effective help inside minimal traumas

Intraoperative monitoring, which has advanced in the 21st century, consists of the motor evoked potential(MEP)and visual evoked potential(VEP). Transcranial stimulation has become the mainstream of MEP from cortical stimulation, and reports of MEP monitoring for the face and lower limbs are increasing. The biggest problem with VEP is poor reproducibility due to inhalation anesthetics. With the increase use of of MEP, total intravenous anesthesia has become common and reproducibility has improved, making it a clinically useful method. I will mention the key points of current intraoperative monitoring in cerebral aneurysm surgery. 1. Selection of type of intraoperative monitoring Is MEP cortical stimulation or transcranial stimulation, upper limb or lower limb? What is VEP? What is somatosensory evoked potential? 2. What to do when the waveform deteriorates or disappears? Remove the clip after clipping. If the blood flow is temporarily occluded, release the occlusion as soon as possible. When the deterioration improves after this maneuver, it should be stopped until the waveform is restored. 3. Pitfall and coping method Anesthesia method. Changes in the stimulation threshold of the transcranial stimulation MEPs. Deterioration/disappearance of MEP waveform after release of brain traction.Rupture of a cerebral aneurysm during surgery carries risks that may lead to poor patient outcomes. Rupture often occurs during the separation procedure of the aneurysm from the surrounding structure. Knowledge regarding the basic principles of operation of surgical apparatus, for example suction devices, before and after the aneurysm rupture event is of paramount importance. It is desirable to deal with these complicated situations automatically in a non-heuristic manner, although some experience and learning are necessary to obtain this ability. When we necessarily apply temporary occlusion of the parent arteries, we need to consider the merits and demerits of temporary occlusion, as well as the limits of the occlusion time in order to prevent ischemic complications.The treatment for cerebral aneurysms has been changing along with the advancements in endovascular treatment. In particular, the induction of a flow-diverter stent can treat even cavernous portion aneurysms, which have been difficult to treat without parent artery occlusion. The definite advantages of the open surgery are low recurrence rates, high angiographic outcome, and bypass. Herein, we describe the bypass method for treating cerebral aneurysms. The purpose of the bypass, difference between high-flow and low-flow bypasses, how to select the donor artery, and variation of bypass technique are described.For safe and reliable cerebral aneurysm clipping, First of all, clean bloodless surgical field and stable and fine movements of micro scissors are necessary. The surgeon must use both hands and determine the best angle before retracting the brain. One of the most basic and important things is that the tips of the clip should be kept continuously in sight until closing clips. We propose a "blading technique" for visualizing the tips of clip blades using a 3-dimensional applier clip manipulation, maintaining contact with the aneurysm while maintaining complementary movement of the suction device in the opposite hand. Before trying to detach the adhering vessels from the aneurysm, the surgeon should consider necessity. Clipping is frequently accomplished using various manipulation techniques with remaining adhesions. This article presents basic clipping and manipulation techniques.The transsylvian approach(TSA)and interhemispheric approach(IHA)are two basic and important surgical approaches for the treatment of cerebral aneurysms. The TSA is usually the first choice for treating middle cerebral artery aneurysms but is sometimes used for treating even anterior communicating artery, internal carotid artery, and basilar artery aneurysms. In contrast, the IHA is usually the first choice for treating anterior communicating artery and distal anterior cerebral artery aneurysms. Young inexperienced neurosurgeons may find these approaches difficult to perform without blood loss. Therefore, the aim of this study was to provide useful tips regarding hemostasis, brain retraction, and intraoperative microscope magnification for performing the TSA and IHA without blood loss by using intraoperative photography.A successful microsurgical neck clipping of cerebral aneurysm is one of the milestones for neurosurgeons. However, a 'complete clip closure of aneurysm without neurological deficit' is not enough for the patient, as esthetic problems can occur several months after the surgery. In this paper, we describe a series of surgical tips concerning the surgical steps starting from skin incision to craniotomy to minimize the esthetic impact. First, the skin incision should be oriented perpendicular to the fall pattern of hair follicles in the temporal area so that the hair covers the scar line and the scalpel is tilted about 50° to face in the frontal area for preservation of hair roots. After minimum coagulation and skin clip application, interfascial fat pad is dissected at 2 cm dorsal to McCarty keyhole to root of zygomatic process, in order to protect facial nerve. Subgaleal connective tissue with periosteum is harvested as a flap for reconstruction of the calvarial defect. The temporal muscle should be dissected from the caudal to rostral position to avoid delayed muscular atrophy. Central dural tenting sutures are placed at the dural incision. The craniotomy line should be filled with bone crust and covered by subgaleal connective tissue with the periosteum. RGDyK nmr Single, short-distance galeal sutures, and loose skin sutures can reduce post-operative granulation. From the day after surgery, the patient can shampoo his/her head.Patient positioning and head fixation are two of the most important aspects of cerebral aneurysm surgery. These procedures require an accurate understanding of the anatomy of the scalp and skull and of the process for approaching aneurysms. We describe the basics of this procedure in frontotemporal craniotomy, which is most frequently used in cerebral aneurysm surgery, with a focus on head fixation using the MAYFIELD three-pin skull clamp(Integra LifeSciences). The insertion sites of the head pins should be avoided in areas with thin bone, such as the frontal sinus and temporal squama, and just above the arteries of the scalp and venous sinuses. The position of the head should be determined based on three factors rotation, vertex up or down, and tilt. The head should be elevated to reduce intracranial pressure, and cervical hyperflexion should be avoided to prevent increased venous pressure.