Colen Surgical Medi CardWhat is a Craniotomy for Aneurysm Clipping?A craniotomy for aneurysm clipping is a direct surgical procedure performed totreat a balloon like bulge or weakening of an artery wall known as an aneurysm.The treatment goal of an aneurysm clipping is to either prevent an aneurysmfrom rupturing or prevent further bleeding from a previously ruptured aneurysm.

Figure 1: Cerebral aneurysm is a dilatation of the wall of an artery in the brain.

What are the indications? When is it used?An aneurysm can be difficult to diagnose as a small, unchanging aneurysm willproduce no symptoms. However, as an aneurysm grows, the artery wall becomes thinner and weaker, often to the point that it leaks or ruptures, releasingblood into the spaces around the brain. This results in either a subarachnoid

Figure 2: A: Treatment Option 1: occluding the aneurysm by placement of an aneurysm clip; B: Treatment Option 2: endovascular placement of a coil into the aneurysm.

half water being sure to use clean cotton pads/balls.Do not put cream or ointment on the stitches/staples.After surgery and during the healing process, it is normal for the scalpand incision to feel numb and/or to become flaky and itch. Remember toavoid scratching the area as this can cause infection and prevent healing.Wound/incision pain and headache are also normal after the surgery.Tylenol/Tylenol Extra Strength can be taken for the pain.

What is the recovery time?Typically, stitches/staples are removed 2 weeks after the procedure. However, this is a general standard time and is not necessarily the time in whichall individuals heal. A follow up office visit should be scheduled 4 6 weeksafter the procedure in order to obtain assessment of the healing and recovery progress.A detailed post operative activity plan and physical therapy / exercise planwill be given to help ease recovery and return to a healthy lifestyle. Patientscan generally resume normal activity in about 1 2 months after undergoingcraniotomy, but this should be discussed with your physician.

plates and small screws (Figure 8).

What are the possible complications?Possible risks and complications associated with this procedure include intraoperative aneurysm rupture; major or perforating artery injury; retraction injury; vasospasm; stroke; seizure; optic nerve injury; vessel occlusion; and imperfectly placed clip possibly requiring reoperation.

What happens after the surgery?After surgery, patients are first taken to the recovery room where they aremonitored as they awake from anesthesia. Patients are then transferred to theIntensive Care Unit for further observation and monitoring. Nausea and headache may be experienced after surgery and thus pain medications are given asneeded. After 24 to 48 hours, you may be transferred to a neurological floorwhere monitoring is continued as you regain strength and your physical activitylevel increases. Upon discharge, most patients are prescribed anti seizure medication, a precaution to prevent seizures after brain surgery. Several monthsafter surgery an electroencephalogram or EEG will be preformed to determineif anti seizure medication should be continued. Usually you will be given asmall breathing device called an �“incentive spirometer�” (Figure 9) which you

can use to expand your lungs while in bed.

Post operative Care of the IncisionDo not remove the stitches or staples.You should shower but NOT bathe, until after the stitches or staples areremoved (usually 2 weeks after surgery).Once the stitches/staples are removed, hair may be shampooed however,do not put hair coloring or gel on the incision site.If dissolvable stitches were used, a shower is permitted 5 days after surgery.The incision may be cleaned with a solution of half hydrogen peroxide and

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Disclaimer: The content presented in this brochure may vary slightly from the actualsurgical procedure.

Figure 9: Use by breathing in deeply and measuring the volume of air your lungs can hold.

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surgical scalpel is used tocarefully open the dura, revealing the brain (Figure 6).The operating microscope isthen brought into the operative field to assist the surgeon in locating the aneurysm. Once the surgeon locates the aneurysm, a clip isapplied to the neck of theaneurysm with meticulouscare (Figure 7). This securesthe aneurysm to preventrupture and bleeding. Uncommonly, the aneurysmmay rupture before or during an operation, at whichpoint the surgeon may placea temporary clip over theparent vessel to preventfurther bleeding. Even morerarely, this may cause thepatient to have a strokewhich is a known surgicalrisk.Once all bleeding has beencontrolled, the brain is irrigated with saline solutionand finally, the bone is replaced and secured with mini

hemorrhage (SAH) or an intracranial hematoma (ICH), both of which constitutea stroke. When an aneurysm ruptures, an individual may experience suddensymptoms that include severe headache, nausea/vomiting, fluctuations in theheartbeat and breathing rate, impaired vision, seizures, and loss of consciousness.Diagnosis of an aneurysm can be difficult but is usually accomplished throughthe use of a magnetic resonance angiography (MRA), a computed tomographyangiography (CTA) and/or contrast angiography (Figure 3). Such diagnostic instruments are used to determine the exact size and location of the aneurysm orsubarachnoid hemorrhage. If a SAH is present, then a surgical clipping procedure is performed within the first three days in order to occlude the ruptureand reduce the risk of re bleeding.

What are the benefits?Although the aneurysm clipping procedure is a more classic approach, it has itsadvantages over the newer endovascular aneurysm coiling procedure. Studieshave shown that individuals who undergo a surgical clipping procedure have adecreased risk of late or recurrent bleed and regrowth.

How will I prepare for the surgery?Preparation before surgery includes scheduling of pre surgical tests (blood test,electrocardiogram, chest x ray) along with the completion and signing of paperwork and consent forms. Before surgery you should avoid using antiplateletagents (such as aspirin, Plavix) or blood thinners (such as coumadin, heparin)since these can increase bleeding during the operation. Smoking is frownedupon since it retards wound healing and should be stopped at least 2 weeksprior to the operation.On the day of your surgery, you will probably be admitted to the hospital earlyin the morning. You shouldn't eat or drink anything after midnight the nightbefore your surgery. If you take any medications, discuss this fact with yourdoctor.

Figure 3: A Head CT showing subarachnoid hemorrhage: B Brain angiogram demonstratinganeurysm .

What happens during surgery?Patients are given a general anesthesia to put them to sleep during the surgery. A breathing tube (endotracheal tube) is placed and the patient breatheswith the assistance of a ventilator. A ventilator is a device that controls andmonitors the flow of air into the lungs. Preoperative intravenous antibioticsare given. The patient is positioned on their back on the operating room tablewith the neck kept in its usual position. The surgical region (head area) iscleansed with a special cleaning solution. Sterile drapes are placed, and thesurgical team wears sterile surgical attire such as gowns and gloves to maintain a bacteria free environment.An incision is made on either the right or left side of the head according to thelocation of the aneurysm. Often, this incision is made behind the hairline tominimize visibility (Figure 4).

An opening in the skull isperformed using a specialhigh speed pneumatic drill,removing the piece of boneto expose the dura (leatherycovering of the brain)(Figure 5).Once the dura is exposed, a

Figure 7: The pertinent blood vessel is traced to theaneurysm, and the aneurysm clipped.

Figure 6: Opening the dura to expose the brain.

Figure 4:: The head is positioned in a

special clamp to hold the head stable.

Figure 5: Bone removed, exposing

dura.

Figure 8: Bone flap replaced and secured with mini

plates and small screws.