# neuro help....



## StacyAnnSC (May 3, 2011)

Can you help with this??? 61700 is aneurysm clipping but this seems more complicated...


PREOPERATIVE DIAGNOSIS:    Ruptured anterior communicating artery aneurysm.   
    POSTOPERATIVE DIAGNOSIS:   Ruptured anterior communicating artery aneurysm.   
    PROCEDURES:   
       1. Left craniotomy for aneurysm clipping.   
       2. Right frontal intracranial pressure monitor placement.   
    SURGEON:         
    ASSISTANT:        neurosurgeon, needed during the   
    critical portions of the case for help with retraction and dissection as   
    well as control of hemorrhage during the aneurysm clipping.  This was   
    needed in spite the fact that a resident was available.   
    RESIDENT:          
    ANESTHESIA:      General with endotracheal intubation.   
    ESTIMATED BLOOD LOSS:  400 mL.   
    COMPLICATIONS:   None.   
    COUNTS:          Sponge and needle counts correct x 2.   
    DETAILS OF THE PROCEDURE:  The patient was brought to the operating room,   
    previously intubated.  Lines were placed.  The left side of her head was   
    clipped and sterilely prepped and draped in the usual fashion.   Her head   
    was placed in a Mayfield headholder and a curvilinear incision was made   
    from the zygoma to the frontal region on the left.  Subcutaneous tissue was   
    dissected using electrocautery.  The Rainey clips were applied.  The   
    temporalis muscle was incised using electrocautery and dissected forward   
    using a periosteal elevator.  Pterion was exposed.  Scalp hooks were placed   
    to hold the skin in place.  Several bur holes were drilled and the dura   
    beneath was stripped using a Penfield 3.  A craniotome bit was used to   
    connect the bur holes and remove a bone flap.  During this, the dura was   
    lacerated.  The brain was also very swollen and extended out of the dura.   
    At this time, the mannitol which had been previously administered had not   
    created a urinary response.  Lasix was added without much of a response.   
    This was likely due to her kidney failure.   A frontal ventriculostomy was   
    placed under direct visualization of the cortex and drained spinal fluid   
    with some relief of the pressure.  A Budde halo was placed and   
    self-retaining retractors were placed to elevate the frontal lobe and   
    expose the optical carotid triangle.  The brain was somewhat relaxed after   
    this and the Budde halo was placed to aide with self-retaining retractors.   
    The microscope was brought in.  At this point,   
    Dr.       scrubbed in to the case.  The optical carotid triangle was   
    found.  The left frontal lobe was elevated and a gyrus rectus resection was   
    performed to expose the anterior cerebral artery as it was initially   
    thought to be the A1 segment.  Dissection of the subarachnoid space and the   
    surrounding hemorrhage was done.  Multiple branches were identified and   
    what appeared to be a frontal polar branch was identified.  It was very   
    difficult to find the aneurysm or most of the vessels.  Resection distal   
    along the artery was performed and the opposite A2 segment was picked up   
    with significant brain retraction  There was a laceration to the underlying   
    left frontal lobe and temporal tip.  This created bleeding, which made it   
    difficult for visualization.  We then tried to follow the vessels   
    proximally.  As we did this, the ipsilateral A1 segment was identified, and   
    then the aneurysm dome at the anterior communicating artery segment.  The   
    neck was dissected out very easily and clips were sized.  A Sugita straight   
    titanium clip that was 7 mm was sized and as additional dissection was   
    done, the aneurysm was ruptured.  This created a significant amount of   
    blood flow with both surgeons aspirating of maintain view of the aneurysm.   
    The clip was placed across the base which stopped the bleeding.  Total   
    blood was 400 mL, none of which was after this point.  The patient was not   
    transfused as a result of this.  Doppler was used to confirm flow in the   
    distal vessels and hemostasis was achieved of the frontal lobes where they   
    had been contused using Surgicel and Gelfoam.  The retractors were removed.   
    Once hemostasis was achieved, it was noted that the dura could not be   
    reapproximated completely, and the brain was still herniating out of the   
    craniotomy site to a certain extent.  Dura Repair synthetic dura was placed   
    underneath the existing the dura and a couple tacking sutures were placed.   
    This was not a watertight closure.  The bone flap was then replaced with 3   
    straight cranial plates.  The temporalis muscle was then reapproximated   
    using 2-0 Vicryl sutures.  The galea was reapproximated using 2-0 Vicryl   
    suture.  The skin was closed with staples.  The right frontal region was   
    then sterilely prepped and draped in the usual fashion after clipping the   
    head.  An incision was made in the scalp.  A twister was used to place a   
    bur hole.  The Camino draining ventricular bolt was then placed after   
    incising the dura.  No CSF was obtained.  Initial ICP was 17.  It was not   
    attached to a drainage bag.  It was placed to the cranial pressure monitor   
    and was sterilely dressed in the usual fashion.  The patient was returned   
    to the intensive care unit in stable condition.


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