J Neurosurg 76:880-882, 1992
A newly designed puncture needle for suction decompression of giant aneurysms Technical note KAZUHIKO KYOSHIMA, M.D., SItlGEAKI KOBAYASHI, M.D., KENJi WAKUI, M.D., YOSIIIKI ICHINOSE, M.D., AND HIROSttI OKUDERA, M.D. Department of 3/~,urosurgery, Shinshu UniversiO' School of Medicine. Matsumoto, Japan A newly designed puncture needle for aspirating large or giant aneurysms is described. This puncture needle represents a modification of an intravenous catheter with an internal needle. It is designed to prevent blood from leaking when the internal needle is removed and has a lateral tube for aspiration. Following aneurysm puncture with the parent artery temporarily trapped, the catheter is positioned on the head frame with a brain spatula and a self-retaining retractor. Blood is suctioned through the lateral tube with a syringe or the suction system normally used in the operating room.
KEY WORDS instrumentation
"
giant aneurysm
NE problem associated with clipping giant aneurysms, particularly of the internal carotid artery (ICA), is difficulty in completely occluding the neck due to high intraluminal pressure and a thick, broad aneurysm neck. To achieve satisfactory clipping, it is therefore important to relax the aneurysm. A few methods for decompressing giant aneurysms have been reported,~'2'7 but they are often cumbersome. We report a newly designed puncture needle for use in large to giant aneurysms, and a safe easy technique for decompressing the aneurysm.
O
operative technique
.
puncture needle
9
artery, the aneurysm is punctured. The internal needle is removed and the catheter is positioned in the operating field. Blood is suctioned through the lateral tube connected to a syringe or to the operating-room suction system via a stopcock. When continuous suction is necessary because of refilling from collateral circulation, systemic heparinization is recommended to prevent intra-aneurysmal coagulation. This puncture needle and the decompression technique have proved useful in achieving aneurysm collapse and satisfactory clipping in seven cases of large or giant aneurysms arising from various arteries.
Description of Needle and Decompression Technique The puncture needle is modified from an intravenous catheter that consists of a plastic catheter and an internal needle. A valve prevents blood from leaking when the internal needle is removed, and there is a lateral tube for aspiration of blood from the aneurysm (Fig. 1). The puncture needle is available in different sizes (Nos. 21 and 22) and lengths (5, 7, and 10 cm). Puncture and decompression techniques are as follows (Figs. 1 and 2): The base of the needle is attached to a tapered brain spatula connected to the head frame by a lightweight tapered self-retaining retractor made of titanium. 5'6 After temporary trapping of the parent 880
Discussion Several techniques for decompression of giant aneurysms have been reported. The suction decompression technique with a butterfly-type scalp vein needle as proposed by Flamm 2 requires the surgeon to hold the needle by hand; the tip of the needle is also in danger of injuring the aneurysm wall. The retrograde suction decompression technique reported by Batjer and Samson ~ and the "trapping-evacuation" technique by Tamaki, et at., 7 decompress the aneurysm via the cervical carotid artery, so may be used only for ICA aneurysms. J. Neurosurg. / Volume 76/May, 1992
Puncture needle for decompression of aneurysms
Fl•. 1. Photographs of the puncture needle after removal of the internal needle (Jell) and after attachment to the fixation system Oighl). I = catheter: 2 = internal needle; 3 = valve for preventing leakage of blood; 4 = lateral tube; 5 = tapered brain spatula: 6 = lightweight tapered self retaining retractor of titanium; and 7 = head frame.
FIG. 2. Schematic drawing of the puncture needle and the decompression method. The puncture needle is attached to a tapered brain spatula connected to a lightweight tapered selfretaining retractor. The aneurysm is punctured while the internal carotid artery (ICA) is temporarily trapped, and the catheter is positioned after the internal needle is removed. Blood is suctioned through the lateral tube, which is connected to a syringe or the operating-room suction system via a stopcock (arrow,). 1 = temporary clip on the proximal ICA (infraclinoidal segment); 2 = temporary clip on the distal ICA; D = dural ring: and OP = optic nerve.
may be carried out when there is retrograde flow through the ophthalmic artery, posterior communicating artery, or other arterial branches refilling the aneurysm despite temporary trapping of the parent artery. 3) The tip of the plastic catheter does not damage the aneurysm wall except at the puncture point. Temporary occlusion of the proximal ICA is usually achieved extracranially in the cervical portion of the neck for giant ICA aneurysms where intracranial acquisition of proximal control appears difficult. But in recent clinical experience with carotid-ophthalmic artery aneurysms and carotid cave aneurysms, 34 we found that satisfactory proximal control of the ICA is obtained by exposing the infraclinoidal segment of the carotid artery after removing the anterior clinoid process. Furlhermore, in those cases where intracranial proximal control is difficult to obtain, removal of the anterior clinoid process is essential for complete clipping of the aneurysm withot~t causing stenosis o f the ICA. Bleeding from the cavernous sinus is controlled with Oxycel packing and elevation of the head. The needle has a stopper mechanism that prevents blood leakage when the internal needle is removed, and can be used for intraoperative angiography performed in the operating field or for monitoring intraluminal pressure of the intracranial vessels. Disclosure
The advantages of our method are as follows: 1) The catheter of this needle can be held securely and safely by the fixation system, allowing the surgeon to use both hands and to change the catheter position when it impedes the surgeon's technique or vision, The catheter may also remain in place in the operating field while the surgeon continues the procedure and blood can be aspirated when necessary. 2) Continuous suctioning
J. Neurosurg. / Volume 76/May, 1992
This instrument is produced and was offered to us by the Medikit Company, Tokyo, Japan. The company is in the process of obtaining permission from the government of Japan for the sale and distribution of the instrument. References
1. Batjer HH, Samson DS: Retrograde suction decompres881
K. Kyoshima, et al.
2. 3. 4.
5. 6.
sion of giant paraclinoidal aneurysms. Technical note. J Neurosurg 73:305-306, 1990 Flamm ES: Suction decompression of aneurysms Technical note. J Neurosurg 54:275-276, 1981 Kobayashi S, Kyoshima K, Gibo H, el al: Carotid cave aneurysrns of the internal carotid arte~. J Neurosurg 70: 216-221, 1989 Kyoshima K, Kobayashi S: Carotid cave aneurysms of the internal carotid artery, in Sugita K, Shibuya M (eds): Intracranial Aneurysms and Arteriovenous Malformations. Nagoya: Nagoya University Coop Press, 1990, pp 197-207 Sugita K: Microneurosurgical Atlas. Berlin: Springer-Vcrlag, 1985, pp 6-7 Sugita K, Hirota T, Mizutani T, el al: A newly designed
882
multipurpose microneurosurgical head frame. Technical note. J Neurosurg 48:656-657, 1978 7. Tamaki N, Kim S, Ehara K, et al: Giant carotid-ophthalmic artery aneurysms: direct clipping utilizing the "trapping-evacuation" technique. J Neurosurg 74:567-572, 1991
Manuscript received April 30, 1991. Accepted in final form October 23, 1991. Address reprint requests to." Kazuhiko Kyoshima, M.D., Department of Neurosurgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390, Japan.
J. Neurosurg. / Volume 7 6 / M a y , 1992
A newly designed puncture needle for suction decompression of giant aneurysms Technical note KAZUHIKO KYOSHIMA, M.D., SItlGEAKI KOBAYASHI, M.D., KENJi WAKUI, M.D., YOSIIIKI ICHINOSE, M.D., AND HIROSttI OKUDERA, M.D. Department of 3/~,urosurgery, Shinshu UniversiO' School of Medicine. Matsumoto, Japan A newly designed puncture needle for aspirating large or giant aneurysms is described. This puncture needle represents a modification of an intravenous catheter with an internal needle. It is designed to prevent blood from leaking when the internal needle is removed and has a lateral tube for aspiration. Following aneurysm puncture with the parent artery temporarily trapped, the catheter is positioned on the head frame with a brain spatula and a self-retaining retractor. Blood is suctioned through the lateral tube with a syringe or the suction system normally used in the operating room.
KEY WORDS instrumentation
"
giant aneurysm
NE problem associated with clipping giant aneurysms, particularly of the internal carotid artery (ICA), is difficulty in completely occluding the neck due to high intraluminal pressure and a thick, broad aneurysm neck. To achieve satisfactory clipping, it is therefore important to relax the aneurysm. A few methods for decompressing giant aneurysms have been reported,~'2'7 but they are often cumbersome. We report a newly designed puncture needle for use in large to giant aneurysms, and a safe easy technique for decompressing the aneurysm.
O
operative technique
.
puncture needle
9
artery, the aneurysm is punctured. The internal needle is removed and the catheter is positioned in the operating field. Blood is suctioned through the lateral tube connected to a syringe or to the operating-room suction system via a stopcock. When continuous suction is necessary because of refilling from collateral circulation, systemic heparinization is recommended to prevent intra-aneurysmal coagulation. This puncture needle and the decompression technique have proved useful in achieving aneurysm collapse and satisfactory clipping in seven cases of large or giant aneurysms arising from various arteries.
Description of Needle and Decompression Technique The puncture needle is modified from an intravenous catheter that consists of a plastic catheter and an internal needle. A valve prevents blood from leaking when the internal needle is removed, and there is a lateral tube for aspiration of blood from the aneurysm (Fig. 1). The puncture needle is available in different sizes (Nos. 21 and 22) and lengths (5, 7, and 10 cm). Puncture and decompression techniques are as follows (Figs. 1 and 2): The base of the needle is attached to a tapered brain spatula connected to the head frame by a lightweight tapered self-retaining retractor made of titanium. 5'6 After temporary trapping of the parent 880
Discussion Several techniques for decompression of giant aneurysms have been reported. The suction decompression technique with a butterfly-type scalp vein needle as proposed by Flamm 2 requires the surgeon to hold the needle by hand; the tip of the needle is also in danger of injuring the aneurysm wall. The retrograde suction decompression technique reported by Batjer and Samson ~ and the "trapping-evacuation" technique by Tamaki, et at., 7 decompress the aneurysm via the cervical carotid artery, so may be used only for ICA aneurysms. J. Neurosurg. / Volume 76/May, 1992
Puncture needle for decompression of aneurysms
Fl•. 1. Photographs of the puncture needle after removal of the internal needle (Jell) and after attachment to the fixation system Oighl). I = catheter: 2 = internal needle; 3 = valve for preventing leakage of blood; 4 = lateral tube; 5 = tapered brain spatula: 6 = lightweight tapered self retaining retractor of titanium; and 7 = head frame.
FIG. 2. Schematic drawing of the puncture needle and the decompression method. The puncture needle is attached to a tapered brain spatula connected to a lightweight tapered selfretaining retractor. The aneurysm is punctured while the internal carotid artery (ICA) is temporarily trapped, and the catheter is positioned after the internal needle is removed. Blood is suctioned through the lateral tube, which is connected to a syringe or the operating-room suction system via a stopcock (arrow,). 1 = temporary clip on the proximal ICA (infraclinoidal segment); 2 = temporary clip on the distal ICA; D = dural ring: and OP = optic nerve.
may be carried out when there is retrograde flow through the ophthalmic artery, posterior communicating artery, or other arterial branches refilling the aneurysm despite temporary trapping of the parent artery. 3) The tip of the plastic catheter does not damage the aneurysm wall except at the puncture point. Temporary occlusion of the proximal ICA is usually achieved extracranially in the cervical portion of the neck for giant ICA aneurysms where intracranial acquisition of proximal control appears difficult. But in recent clinical experience with carotid-ophthalmic artery aneurysms and carotid cave aneurysms, 34 we found that satisfactory proximal control of the ICA is obtained by exposing the infraclinoidal segment of the carotid artery after removing the anterior clinoid process. Furlhermore, in those cases where intracranial proximal control is difficult to obtain, removal of the anterior clinoid process is essential for complete clipping of the aneurysm withot~t causing stenosis o f the ICA. Bleeding from the cavernous sinus is controlled with Oxycel packing and elevation of the head. The needle has a stopper mechanism that prevents blood leakage when the internal needle is removed, and can be used for intraoperative angiography performed in the operating field or for monitoring intraluminal pressure of the intracranial vessels. Disclosure
The advantages of our method are as follows: 1) The catheter of this needle can be held securely and safely by the fixation system, allowing the surgeon to use both hands and to change the catheter position when it impedes the surgeon's technique or vision, The catheter may also remain in place in the operating field while the surgeon continues the procedure and blood can be aspirated when necessary. 2) Continuous suctioning
J. Neurosurg. / Volume 76/May, 1992
This instrument is produced and was offered to us by the Medikit Company, Tokyo, Japan. The company is in the process of obtaining permission from the government of Japan for the sale and distribution of the instrument. References
1. Batjer HH, Samson DS: Retrograde suction decompres881
K. Kyoshima, et al.
2. 3. 4.
5. 6.
sion of giant paraclinoidal aneurysms. Technical note. J Neurosurg 73:305-306, 1990 Flamm ES: Suction decompression of aneurysms Technical note. J Neurosurg 54:275-276, 1981 Kobayashi S, Kyoshima K, Gibo H, el al: Carotid cave aneurysrns of the internal carotid arte~. J Neurosurg 70: 216-221, 1989 Kyoshima K, Kobayashi S: Carotid cave aneurysms of the internal carotid artery, in Sugita K, Shibuya M (eds): Intracranial Aneurysms and Arteriovenous Malformations. Nagoya: Nagoya University Coop Press, 1990, pp 197-207 Sugita K: Microneurosurgical Atlas. Berlin: Springer-Vcrlag, 1985, pp 6-7 Sugita K, Hirota T, Mizutani T, el al: A newly designed
882
multipurpose microneurosurgical head frame. Technical note. J Neurosurg 48:656-657, 1978 7. Tamaki N, Kim S, Ehara K, et al: Giant carotid-ophthalmic artery aneurysms: direct clipping utilizing the "trapping-evacuation" technique. J Neurosurg 74:567-572, 1991
Manuscript received April 30, 1991. Accepted in final form October 23, 1991. Address reprint requests to." Kazuhiko Kyoshima, M.D., Department of Neurosurgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390, Japan.
J. Neurosurg. / Volume 7 6 / M a y , 1992
