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In this technical note, the authors describe the management of a right inferior MCA-trunk tear after a cotton patty became entangled in the drill, which then caused the MCA branches to wrap around the drill [2]. This occurred during an intradural anterior clinoidectomy as part of the clipping of a posterior communicating and anterior choroidal artery aneurysm clipping. The tear could be primarily repaired with interrupted 10.0 stitches, without causing an obvious change in lumen diameter. Two small branches were avulsed and were coagulated; the 2 aneurysms were subsequently successfully clipped and the patient woke up without a neurological deficit.
We would like to thank the authors for publishing this complication. A recent systematic on the management of large vessel injury in open skull base surgery yielded only 12 articles [5]. This highlights a phenomenon of complication underreporting, whilst the educational value of these reports is tremendous.
No comments can be made on the technical expertise with which this complication was handled. The key points are all valuable and clearly written by an experienced surgeon.
However in our opinion the main message of this report should be: when the drill goes in, every cottonoid patty in the operative field should be removed. ‘Drill in, patty out!’ is one of the principles in skull base and cerebrovascular surgery. The risk of turning a patty into a brush cutter or a projectile when contacting a high-speed drill bit is well described [1, 3, 4, 6]. Apart from the extradural clinoidectomy, some alternative strategies to protect the adjacent brain are spatulas, reflecting the dura or using wet gelfoam [3, 4]. By applying this principle, similar (or worse) complications can be prevented by surgeons with less experience.
References
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Keleş A, Gürbüz M, Erginoğlu U, Başkaya MK (2022) How I do it: management of M2 tear injury caused by drilling during intradural anterior clinoidectomy for microsurgical clipping of intracranial aneurysms. Acta Neurochir. https://doi.org/10.1007/s00701-022-05189-8
Kozák J, Bízik I, Novotný M, Klener J (2022) How I do it: optic canal unroofing in surgery for tuberculum sellae meningiomas with compression of the optic nerve. Acta Neurochir. https://doi.org/10.1007/s00701-021-05083-9
Sai Kiran NA, Furtado SV, Hegde AS (2013) How I do it : anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment aneurysms. Acta Neurochir 155(6):1025–1029. https://doi.org/10.1007/s00701-013-1685-1
Van Der Veken J, Simons M, Mulcahy MJ, Wurster C, Harding M, Van Velthoven V (2021) The surgical management of intraoperative intracranial internal carotid artery injury in open skull base surgery-a systematic review. Neurosurg Rev. https://doi.org/10.1007/s10143-021-01692-1
Yang T, Da Silva HD, Sekhar LN (2018) Surgical positioning, navigation, important surgical tools, craniotomy, and closure of cranial and spinal wounds. In: Ellenbogen RG, Sekhar LN, Kitchen ND, Brito da Silva H (eds) Principles of neurological surgery 4th edn. Elsevier, p 103–115
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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. Acta Neurochir (Wien). 2022 Mar 26. https://doi.org/10.1007/s00701-022-05189-8. Online ahead of print.
This article is part of the Topical Collection on Neurosurgical Technique Evaluation
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Van Der Veken, J., Van Velthoven, V. Drill in, patties out. Acta Neurochir 164, 2545–2546 (2022). https://doi.org/10.1007/s00701-022-05208-8
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DOI: https://doi.org/10.1007/s00701-022-05208-8