Muslin gauze in intraeranial vascular surgery Technical note
J. LAWRENCE POOL, M . D .
Columbia University Medical School, New York, New York
u,' The author comments on three ways in which he has found muslin gauze an aid to clotting in intracranial vascular surgery. KEY W O R D S
9
muslin gauze
N 1958, Gillingham first described the use of muslin to wrap intracranial aneurysms, x and in the early 1960's the writer introduced this technique to the Neurological Institute of New York? "Aneurysms may be snugly and completely wrapped with hammered strips of muscle, fine-meshed gauze, or G e l f o a m . . . muscle wrapping does not always succeed in preventing recurrent hemorrhage or expansion of the aneurysm and Gelfoam is even less reliable in these respects . . . . A (gauze) wrapping procedure may be the treatment of choice for aneurysms that do not lend themselves to clipping or ligating, either because of a broad base or brittle arteriosclerotic plaques, or because of their location at a bifurcation or trifurcation. ''~ My results 3,5 and those recently reported by Mount and Antunes, 2 testify to the effectiveness of gauze wrapping for certain aneurysms. Renewed interest in the use of muslin gauze in vascular surgery has prompted this note on two other ways in which muslin can be used to advantage: to seal a leak from an injured cerebral artery, and to occlude excep-
I
J. Neurosurg. / Volume 44 /January, 1976
9
vascular surgery
9
aneurysm
tionally large venous channels of the tentorium. Sealing a Cerebral Arterial Leak
In 1970, this author developed another use of muslin gauze in intracranial surgery, reported in 1972 as follows: "The application of tiny squares of muslin, title linen, or gauze, as advocated by Gillingham, is also an effective and simple method for stopping bleeding from a tear in an intracranial artery or aneurysm that cannot be safely occluded. One simply applies three or four squares of muslin, each about 4 • 4 mm, in layers over the bleeding point and then places cottonoid over them, held gently but firmly in place with a small caliber suction tip for 20 minutes or more. ''a I have used this technique in six cases, with complete neurological recovery in all but one. In three cases, after I clipped the neck of an aneurysm of an internal carotid artery, the artery developed a leak because the wall was friable as a result of arteriosclerotic softening. In two other cases, each with an aneu127
J. L. Pool rysm of the anterior communicating artery, an anterior cerebral artery developed a small tear when a tiny branch of the artery was inadvertently avulsed. One of these patients recovered fully, but the other was left with moderate intellectual deficit. In the sixth case, during surgery for an aneurysm of the dominant middle cerebral artery, a small aperture was created in the artery from avulsion of one of its tiny branches. The leak was successfully stopped by muslin and the patient staged a perfect recovery. A word of caution should be given. Blood usually leaks through the gauze and overlying cottonoid which have been applied to the vessel for several minutes, depending on the size of the artery and the width of the aperture. The sight of this continued oozing may tempt the surgeon to press down heavily upon the cottonoid with his suction tip, but he should resist this temptation. After a short interval, with no pressure and with just continuous gentle suction, the bleeding will stop as clotting occurs within the meshes of the gauze. If one were to press heavily upon the artery, already compromised by local trauma and vasospasm, one might so narrow its lumen that it could become thrombosed. I have no reason to believe that thrombosis has occurred in any vessel so treated, but I am not certain of this because postoperative arteriography was not performed in any of the six cases just cited. Occlusion of Large Venous Channels
Muslin is also helpful in the occlusion of exceptionally large venous channels in or near the center of one leaf of the tentorium. My experience with this has included three cases: in one patient these channels were opened during removal of a large tentorial meningioma, in another for the removal of an overlying temporal lobe arteriovenous malformation, and in the third for invasive cylindroma
]28
of the tentorium. In these three cases, when efforts to cease the flow of blood by ligatures, clips, and large muscle stamps had failed, the gaping channels were quickly and simply occluded by stuffing them with just enough muslin to stop the bleeding. All three patients recovered. Again a word of caution is in order. A thread should be passed through the muslin before inserting the muslin in the lumen of the venous channel. The suture material enables the surgeon to control the muslin and also to anchor it securely to the tentorium after it has been placed in the venous channel. Wek clips have also been used to anchor the muslin to the tentorium. Comment
In summary, there are three ways in which muslin gauze may be found useful in intracranial surgery: for wrapping certain aneurysms; for sealing a leaking or torn cerebral artery; and for occluding exceptionally large venous channels of the tentorium. 4 References
1. Gillingham F J: The management of ruptured intracranial aneurysm. Hunterian Lecture. Ann R Coil Surg Eng 23:89-117, 1958 2. Mount LA, Antunes JL: Result of treatment of intracranial aneurysrns by wrapping and coating. J Neurosurg 42:189-193, 1975 3. Pool JL: Bifrontal craniotomy for anterior communicating artery aneurysms. J Neurosurg 36:212-220, 1972 4. Pool JL: The Neurological Institute of New York: 1909-1974. With personal anecdotes,
Privately printed, Lakeville, Conn, Pocket Knife Press, 1975 5. Pool JL, Potts DG: Anenrysms and Arteriovenous Malformations of the Brain, New York, Harper & Row, 1965 Address reprint requests to: J. Lawrence Pool, M.D., Box 31, West Cornwall, Connecticut 06796.
J. Neurosurg. / Volume 44 /January, 1976
J. LAWRENCE POOL, M . D .
Columbia University Medical School, New York, New York
u,' The author comments on three ways in which he has found muslin gauze an aid to clotting in intracranial vascular surgery. KEY W O R D S
9
muslin gauze
N 1958, Gillingham first described the use of muslin to wrap intracranial aneurysms, x and in the early 1960's the writer introduced this technique to the Neurological Institute of New York? "Aneurysms may be snugly and completely wrapped with hammered strips of muscle, fine-meshed gauze, or G e l f o a m . . . muscle wrapping does not always succeed in preventing recurrent hemorrhage or expansion of the aneurysm and Gelfoam is even less reliable in these respects . . . . A (gauze) wrapping procedure may be the treatment of choice for aneurysms that do not lend themselves to clipping or ligating, either because of a broad base or brittle arteriosclerotic plaques, or because of their location at a bifurcation or trifurcation. ''~ My results 3,5 and those recently reported by Mount and Antunes, 2 testify to the effectiveness of gauze wrapping for certain aneurysms. Renewed interest in the use of muslin gauze in vascular surgery has prompted this note on two other ways in which muslin can be used to advantage: to seal a leak from an injured cerebral artery, and to occlude excep-
I
J. Neurosurg. / Volume 44 /January, 1976
9
vascular surgery
9
aneurysm
tionally large venous channels of the tentorium. Sealing a Cerebral Arterial Leak
In 1970, this author developed another use of muslin gauze in intracranial surgery, reported in 1972 as follows: "The application of tiny squares of muslin, title linen, or gauze, as advocated by Gillingham, is also an effective and simple method for stopping bleeding from a tear in an intracranial artery or aneurysm that cannot be safely occluded. One simply applies three or four squares of muslin, each about 4 • 4 mm, in layers over the bleeding point and then places cottonoid over them, held gently but firmly in place with a small caliber suction tip for 20 minutes or more. ''a I have used this technique in six cases, with complete neurological recovery in all but one. In three cases, after I clipped the neck of an aneurysm of an internal carotid artery, the artery developed a leak because the wall was friable as a result of arteriosclerotic softening. In two other cases, each with an aneu127
J. L. Pool rysm of the anterior communicating artery, an anterior cerebral artery developed a small tear when a tiny branch of the artery was inadvertently avulsed. One of these patients recovered fully, but the other was left with moderate intellectual deficit. In the sixth case, during surgery for an aneurysm of the dominant middle cerebral artery, a small aperture was created in the artery from avulsion of one of its tiny branches. The leak was successfully stopped by muslin and the patient staged a perfect recovery. A word of caution should be given. Blood usually leaks through the gauze and overlying cottonoid which have been applied to the vessel for several minutes, depending on the size of the artery and the width of the aperture. The sight of this continued oozing may tempt the surgeon to press down heavily upon the cottonoid with his suction tip, but he should resist this temptation. After a short interval, with no pressure and with just continuous gentle suction, the bleeding will stop as clotting occurs within the meshes of the gauze. If one were to press heavily upon the artery, already compromised by local trauma and vasospasm, one might so narrow its lumen that it could become thrombosed. I have no reason to believe that thrombosis has occurred in any vessel so treated, but I am not certain of this because postoperative arteriography was not performed in any of the six cases just cited. Occlusion of Large Venous Channels
Muslin is also helpful in the occlusion of exceptionally large venous channels in or near the center of one leaf of the tentorium. My experience with this has included three cases: in one patient these channels were opened during removal of a large tentorial meningioma, in another for the removal of an overlying temporal lobe arteriovenous malformation, and in the third for invasive cylindroma
]28
of the tentorium. In these three cases, when efforts to cease the flow of blood by ligatures, clips, and large muscle stamps had failed, the gaping channels were quickly and simply occluded by stuffing them with just enough muslin to stop the bleeding. All three patients recovered. Again a word of caution is in order. A thread should be passed through the muslin before inserting the muslin in the lumen of the venous channel. The suture material enables the surgeon to control the muslin and also to anchor it securely to the tentorium after it has been placed in the venous channel. Wek clips have also been used to anchor the muslin to the tentorium. Comment
In summary, there are three ways in which muslin gauze may be found useful in intracranial surgery: for wrapping certain aneurysms; for sealing a leaking or torn cerebral artery; and for occluding exceptionally large venous channels of the tentorium. 4 References
1. Gillingham F J: The management of ruptured intracranial aneurysm. Hunterian Lecture. Ann R Coil Surg Eng 23:89-117, 1958 2. Mount LA, Antunes JL: Result of treatment of intracranial aneurysrns by wrapping and coating. J Neurosurg 42:189-193, 1975 3. Pool JL: Bifrontal craniotomy for anterior communicating artery aneurysms. J Neurosurg 36:212-220, 1972 4. Pool JL: The Neurological Institute of New York: 1909-1974. With personal anecdotes,
Privately printed, Lakeville, Conn, Pocket Knife Press, 1975 5. Pool JL, Potts DG: Anenrysms and Arteriovenous Malformations of the Brain, New York, Harper & Row, 1965 Address reprint requests to: J. Lawrence Pool, M.D., Box 31, West Cornwall, Connecticut 06796.
J. Neurosurg. / Volume 44 /January, 1976
