Pre-operative case presentation
Dr. Kazi Saiful Islam
Resident , Phase B
Department of Neurosurgery
BSMMU
06.08.22 Yellow unit

Particulars of the patient
 Name : Mrs. Afroza
 Age : 38 years
 Sex : Female
 Marital status : Married
 Occupation : Housewife
 Address : Narayanganj
 DOA : 19/06/2022
 R/N : 395/03
 Ward : 3/B
 Bed : FNP- 09

Chief complaints
Sudden severe headache 2 months back

According to the statement of the patient, she was reasonably well about 2
months back. Then she developed sudden severe thunderclap headache,
which was global & associated with altered sensorium, restlessness and
several episodes of vomiting. She described it as the worst headache of her
life. Headache aggravated on movement & relieved partially with medication.
Presenting complaints

But there is no history loss of consciousness, convulsion, weakness of
any side of the body, bowel and bladder incontinence, photophobia,
neck pain or neck stiffness, visual disturbance during the time of the
incidence.
She had no history of such kind of headache earlier or headache which
aggravated with bright light, loud noise, menstruation or consuming
certain foods like cheese, chocolate etc & there is no family history
either.

• With above complaints, she got admitted into BSMMU for specific
management.

Associated illness
Disease Duration Drugs
Diabetes - -
Hypertension - -
Bronchial Asthma - -
Hypo/hyperthyroidism - -
CKD - -

Past medical history
 Childhood illness: Nothing significant
 History of surgery: Underwent two Cesarean sections.
 Drug History: Tab. Nimodipine 30 mg, Tab. Paracetamol 500 mg, Tab Levetiracetam.
 Immunization: BCG mark present on the left arm.
 Accident/Injury: Nothing significant
 Personal history – She is non-smoker, non-alcoholic, not used to take betel nut
 Family history- All of her family members are in good health.
 Socioeconomic history- She belongs to low socio-economic status.

Menstrual history
• Age of menarche – 14 years
• Menstrual flow – Average
• Menstrual cycle - Regular

General Examination
 Appearance : ill looking
 Body built : Average
 Co-operative
 Decubitus : on choice
 Weight : 58 kgs
 Anaemia : absent
 Cyanosis : absent
 Joundice : absent

 Edema : absent
 Dehydration : absent
 BP :130/85 mm of Hg
 Pulse :84 b/min
 Temp : 98 f
 Skin condition : Normal
 No lymphadenopathy

Systemic examination
• Respiratory system
• Cardiovascular system
• Alimentary system
Normal findings

Neurological Examination
 Higher psychic function: Intact
 GCS-15
 Handedness: Right handed
 Speech : Normal
 Gait : Normal
 Lobe sign : Absent
 Normal cerebellar functions.
 No signs of meningeal irritation.

Cranial Nerves examination
Olfactory Nerve: Normal
Optic Nerve:
Visual Acuity: 6/6 both eyes.
Visual Field exam on Confrontation testing: Normal in both eyes
Color vision: Normal in both eyes.
Fundoscopy Exam: Normal in both eyes.

Visual Field Analysis

Colour Fundal Photograph

Oculomotor, Trochlear & Abducens nerve
EOM: Intact Bilaterally
Diplopia: Absent
Nystagmus: Absent
Pupil
Rt Lt
size 3 mm 3mm
shape round round
Direct
light
reflex
intact intact
Indirect
light
reflex
Intact Intact
Accommodation reflex intact

Trigeminal nerve (V)
 Sensory: Intact to all modalities in all the three divisions.
 Corneal Reflex:. Intact (B/L).
 Motor (Muscles of Mastication): Intact Bilaterally
 Jaw Jerk: Absent

Facial Nerve : Intact
Auditory Nerve :
Rt Lt
Hearing Normal Normal
Rinne Test AC>BC AC>BC
Weber Test Central

Glossopharyngealand Vagus nerve
Voice Intact
Gag reflex Intact
Swallowing Normal
Position of uvula Central
Palatal movement symmetrical

AccessoryNerve (XI)
Hypoglossal Nerve (XII)
Rt Lt
Sternomastoid Intact Intact
Trapezius Intact Intact
Deviation of Tongue No
Atrophy of tongue muscle Absent
Fasciculation Absent

Upper limb motor examination
Right Left
Bulk Normal Normal
Tone Normal Normal
Power Elbow flexors 5 5
Wrist extensors 5 5
Elbow extensors 5 5
Finger flexors 5 5
Finger adductors 5 5
Jerks Biceps Normal Normal
Triceps Normal Normal
Supinator Normal Normal
Hoffman Negative Negative

Lower limb motor examination
Right Left
Bulk Normal Normal
Tone Normal Normal
Power Hip flexors 5 5
Hip extensors 5 5
Hip adductors 5 5
Hip abductors 5 5
Knee flexors 5 5
Knee extensors 5 5
Ankle dorsiflexors 5 5
EHL 5 5
Ankle planter flexors 5 5

Jerks Right Left
Knee Normal Normal
Ankle Normal Normal
Planter Flexor Flexor
Clonus Patellar Absent Absent
Ankle Absent Absent

Sensory examination
All modalities of sensations are intact in both upper limbs and lower limbs

Clinical diagnosis
Headache due to vascular event
(most probably due to subarachnoid hemorrhage)

INVESTIGATIONS

Plain CT scan of head Axial
sections

Plain CT scan of head Axial
sections

Clinico-radiological Diagnosis
Sub arachnoid hemorrhage due to Ruptured aneurysm on M1 segment
of the right MCA.
(Hunt and Hess grade – 3)

Plan
Right pterional craniotomy and clipping of the aneurysm

Position
• The patient is placed in a supine position with the head slightly extended and rotated toward the left side.
• Head is above heart level to optimize venous return

SKIN INCISION
Curvilinear skin incision starting at the root of the zygomatic arch, just 5 mm in front of the tragus, which runs
vertically upward. Once it passes the ear, it is curved superiorly toward the ipsilateral frontal region until it reaches
the midline ,always keeping behind the hairline.

Exposing temporalis fascia

Inter-Fascial Dissection

Two burr holes will be made, one at the posterior insertion of the zygomatic arch. The second burr hole is made at
the intersection of the zygomatic bone, superior temporal line, and supraorbital ridge.
Craniotomy will be done along the shown line by connecting the burr hole.
Craniotomy

Extradural Bony Work

Durotomy

Sylvian fissure dissection
• The Sylvian fissure is dissected open along its anterior limb.

Dissection and clipping Strategy
 Preserve veins
 Gentle dissection and dynamic retraction/ avoid retraction
 Proximal Control at M1
 Dissection of neck
 Clip size: 3X1.5= 4.5 mm or more

MCA aneurysm dissection
Distal to proximal aneurysm dissection
1. Following the superior trunk (outer)
2. Proximal control of M1
3. Following the superior trunk (inner)
4. Following the inferior trunk (inner)
5. dissection of the distal neck

MCA aneurysm dissection
1. Dissecting of supraclinoid ICA
2. Dissecting the A1 ACA
3. identyfiing the AChA laterally and dissecting
the proximal M1
4. Gaining proximal control
5. Back to the sylvian fissure and following
sup. Trunk (outer)
6. Following the sup trunk (inner)
7. Following the inferior trunk (inner)
8. Dissecting the distal neck
Proximal to distal MCA aneurysm dissection

Clipping

Intraoperative aneurysm rupture
The technical response to intraoperative aneurysm rupture is an ordered
sequence of steps
 tamponade
 suction
 proximal control with temporary clipping,
 distal control with temporary clipping,
 permanent aneurysm clipping.

Post-clipping inspection
Inspection checks seven points:
 Aneurysm occlusion,
 Patency of the parent artery,
 Efferent branches,
 Perforating arteries,
 Adjacent arteries,
 No neck remnant beneath the clips
 Surgical blind spots

Closure
• After maintaining proper hemostasis, dura is closed in water tight
fashion.
• Reposition of bone flap
• Finally, the scalp is closed in anatomic layers.

Complications
Per-operative Postoperative
Retraction injury to Frontal lobe Post operative seizure
Injury to sylvian vein Vasospasm
Occlusion of M1 CSF leak
Aneurysmal rupture Infection
Inadequate/ incomplete clipping

THANK YOU

Dural incision

Incision and dissection
A curvilinear skin incision begins at zygomatic arch 1 cm anterior to tragus and arcs to
midline just behind the hairline at widow’s peak.

Burr hole and craniotomy

Strip the dura away from the roof of the orbit and also from the frontal and temporal surface of
lateral sphenoid ridge by using penfield 1 dissector

Removal of mid sphenoid ridge by rongeur and sphenoid ridge is drilled flat

Splitting the sylvian fissure