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Similar a MCA.pptx(20)



  1. Pre-operative case presentation Dr. Kazi Saiful Islam Resident , Phase B Department of Neurosurgery BSMMU 06.08.22 Yellow unit
  2. 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
  3. Chief complaints Sudden severe headache 2 months back
  4. 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
  5. 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.
  6. • With above complaints, she got admitted into BSMMU for specific management.
  7. Associated illness Disease Duration Drugs Diabetes - - Hypertension - - Bronchial Asthma - - Hypo/hyperthyroidism - - CKD - -
  8. 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.
  9. Menstrual history • Age of menarche – 14 years • Menstrual flow – Average • Menstrual cycle - Regular
  10. General Examination  Appearance : ill looking  Body built : Average  Co-operative  Decubitus : on choice  Weight : 58 kgs  Anaemia : absent  Cyanosis : absent  Joundice : absent
  11.  Edema : absent  Dehydration : absent  BP :130/85 mm of Hg  Pulse :84 b/min  Temp : 98 f  Skin condition : Normal  No lymphadenopathy
  12. Systemic examination • Respiratory system • Cardiovascular system • Alimentary system Normal findings
  13. 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.
  14. 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.
  15. Visual Field Analysis
  16. Colour Fundal Photograph
  17. 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
  18. 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
  19. Facial Nerve : Intact Auditory Nerve : Rt Lt Hearing Normal Normal Rinne Test AC>BC AC>BC Weber Test Central
  20. Glossopharyngealand Vagus nerve Voice Intact Gag reflex Intact Swallowing Normal Position of uvula Central Palatal movement symmetrical
  21. AccessoryNerve (XI) Hypoglossal Nerve (XII) Rt Lt Sternomastoid Intact Intact Trapezius Intact Intact Deviation of Tongue No Atrophy of tongue muscle Absent Fasciculation Absent
  22. 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
  23. 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
  24. Jerks Right Left Knee Normal Normal Ankle Normal Normal Planter Flexor Flexor Clonus Patellar Absent Absent Ankle Absent Absent
  25. Sensory examination All modalities of sensations are intact in both upper limbs and lower limbs
  26. Clinical diagnosis Headache due to vascular event (most probably due to subarachnoid hemorrhage)
  28. Plain CT scan of head Axial sections
  29. Plain CT scan of head Axial sections
  30. Clinico-radiological Diagnosis Sub arachnoid hemorrhage due to Ruptured aneurysm on M1 segment of the right MCA. (Hunt and Hess grade – 3)
  31. Plan Right pterional craniotomy and clipping of the aneurysm
  32. 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
  33. 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.
  34. Exposing temporalis fascia
  35. Inter-Fascial Dissection
  36. 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
  37. Extradural Bony Work
  38. Durotomy
  39. Sylvian fissure dissection • The Sylvian fissure is dissected open along its anterior limb.
  40. 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
  41. 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
  42. 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
  43. Clipping
  44. 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.
  45. 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
  46. Closure • After maintaining proper hemostasis, dura is closed in water tight fashion. • Reposition of bone flap • Finally, the scalp is closed in anatomic layers.
  47. 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
  49. Dural incision
  50. 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.
  51. Burr hole and craniotomy
  52. 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
  53. Removal of mid sphenoid ridge by rongeur and sphenoid ridge is drilled flat
  54. Splitting the sylvian fissure

Notas do Editor

  1. Separation of dura from orbital roof and sphenoid wing. Bony sphenoid ridge is removed with rongeurs or smoothened with drill.