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How I do it: management of M2 tear injury caused by drilling during intradural anterior clinoidectomy for microsurgical clipping of intracranial aneurysms

  • How I Do it - Vascular Neurosurgery - Aneurysm
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Abstract

Background

High-speed drilling is associated with potential injury to neurovascular structures, particularly during intradural drilling of the anterior clinoid process.

Method

During an anterior clinoidectomy, a cotton patty and middle cerebral artery branches became inadvertently wrapped around the bit, causing a tear on the inferior M2 trunk. Following temporary clipping of the internal carotid artery, the tear was identified. Temporary clips were placed proximally and distally. The tear was then repaired with interrupted microsutures.

Conclusion

Extreme care should be exercised during clinoidectomy. Should small vascular injury occur, direct microsuturing can be a good alternative to sacrificing or implantation anastomosis repair.

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Author information

Authors and Affiliations

  1. Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA

    Abdullah Keleş, Mehmet Sabri Gürbüz, Ufuk Erginoğlu & Mustafa Kemal Başkaya

Authors
  1. Abdullah Keleş
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  2. Mehmet Sabri Gürbüz
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  3. Ufuk Erginoğlu
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  4. Mustafa Kemal Başkaya
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Corresponding author

Correspondence to Mustafa Kemal Başkaya.

Ethics declarations

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

The authors declare no competing interests. Senior Author (MKB) is a Stryker consultant.

Additional information

Key points

1. Drilling of the ACP is associated with a risk of injury to neurovascular structures even in experienced hands.

2. Many complications have been reported that are associated with drilling, including CSF leaks, optic nerve injury, oculomotor palsy, vascular injury, and both direct injury from the rotating tip of the drill and indirect thermal injury from the heating effect of the power drill.

3. In the paraclinoidal region, surgical exposure is hampered by the anterior clinoid process and drilling the ACP enhances the exposure.

4. Anterior clinoidectomies can be performed in extra- or intradural fashion.

5. Extreme care should be exercised during clinoidectomy, and normal vasculature should be carefully preserved.

6. Vascular injury is a drilling complication that can be catastrophic if not handled properly.

7. With skull base and cerebrovascular surgeries, the surgical team should be versatile and ready to perform salvaging procedures.

8. If a tear is small, direct microsuturing may be a good alternative to sacrificing or implantation of the artery.

9. Blood transfusion, adenosine and barbiturates should be readily available, and normovolemia and normotension should be maintained by the anesthesia team.

10. No matter how experienced the surgeon, the procedure should never be underestimated.

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This article is part of the Topical Collection on Vascular Neurosurgery – Aneurysm

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Keleş, A., Gürbüz, M.S., Erginoğlu, U. et al. How I do it: management of M2 tear injury caused by drilling during intradural anterior clinoidectomy for microsurgical clipping of intracranial aneurysms. Acta Neurochir 164, 2541–2544 (2022). https://doi.org/10.1007/s00701-022-05189-8

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  • DOI: https://doi.org/10.1007/s00701-022-05189-8

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