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Clipping is a surgical procedure performed to treat a balloon-like bulge or weakening of an artery wall known as an aneurysm. As an aneurysm grows it becomes thinner and weaker. It can become so thin that it leaks or ruptures, releasing blood into the spaces around the brain - called a subarachnoid hemorrhage (SAH). A neurosurgeon places a tiny clip across the neck of the aneurysm to stop or prevent an aneurysm from bleeding.

Am I A Candidate?

You May Be A Candidate For Clipping If You Have A: -

Ruptured aneurysm - clipping is the traditional treatment for aneurysms associated with SAH. The risk of rebleeding is 35% within the first 14 days after the first bleed. So, timing of surgery is important - usually within 72 hours of the first bleed. Vasospasm is a common complication of SAH, which must be closely managed after treatment. Additionally, patients suffering a SAH may have short and long-term deficits requiring therapy.

Unruptured aneurysm - clipping of unruptured aneurysms has fewer complications and a faster recovery than ruptured. The choice of treatment options (observation, clipping, or coiling) must be weighed against the risk of rupture. The risk of aneurysm rupture is about 1% per year but may be higher or lower depending on the size and location of the aneurysm; however, when a rupture occurs there is a 40% risk of death and an 80% risk of disability. If the aneurysm is small or in a place that would be difficult to reach, or if the person is in poor health, the surgical treatment may be a greater risk than the aneurysm.

Clipping Rx For Cerebral Aneursym

  • An aneurysm is clipped through a craniotomy, which is a surgical procedure in which the brain and the blood vessels are accessed through an opening in the skull.
  • After the aneurysm is identified, it is carefully dissected (separated) from the surrounding brain tissue.
  • A small metal clip (usually made from titanium) is then applied to the neck (base) of the aneurysm.
  • This decreases the pressure on the aneurysm and prevents it from rupturing.
  • This surgery can be done depending on the location of the aneurysm, its size, and your general health.
  • The clip has a spring mechanism which allows the two "jaws" of the clip to close around either side of the aneurysm, thus occluding (separating) the aneurysm from the parent (origin) blood vessel.

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What Happens During Surgery?

There are six steps to the procedure. The operation generally takes 3-5 hours or longer if a complex craniotomy is planned.

Step 1. Prepare the patient : - You will lie on the operating table and be given general anesthesia. After you are asleep, your head is placed in a three-pin skull fixation device, which attaches to the table and holds your head in position during the procedure. Next, the incision area of the scalp is prepped. Skin incisions are usually made behind the hairline. For better cosmetics immediately after surgery, a hair sparing technique may be used, where only a 1/4-inch wide area along the proposed incision is shaved. However, sometimes the entire incision area may be shaved.

A lumbar drain may be inserted in your lower back to remove cerebrospinal fluid (CSF) and allow the brain to relax during surgery. A brain-relaxing drug (mannitol) may be given.

Step 2. Perform a craniotomy : - Depending on the location of your aneurysm, a bone flap, or craniotomy, will be made in your skull. There are many types of craniotomies. Ask your surgeon to describe exactly where the skin incision will be made and the bone to be removed.

After your scalp is prepped, the surgeon will make a skin incision to expose the skull. The skin and muscles are lifted off the bone and folded back. Next, small burr holes are made in the skull with a drill. The burr holes allow entrance of a special saw called a craniotome. Similar to using a jigsaw, the surgeon cuts an outline of a bone window (Fig. 3). The cut bone flap is lifted and removed to expose the protective covering of the brain, called the dura mater. The bone flap is safely stored and replaced at the end of the procedure.

Step 3. Expose the aneurysm : - The dura is opened and folded back to expose the brain. Retractors are placed on the brain to gently open a corridor between the brain and skull. Working under an operating microscope, the surgeon carefully opens the corridor, locates the artery and follows it to the aneurysm.

Before placing the clip, the surgeon obtains control of the blood flow in and out of the aneurysm. Handling of the aneurysm, especially the dome, can cause rupture. Should rupture occur during surgery, a temporary clip can be placed across the parent artery to stop the bleeding. Depending on the aneurysm size and location, vascular control may be obtained at the carotid artery in the neck through a separate incision.

Step 4. Insert the clip : - Once vascular control is achieved, the aneurysm neck is prepared for clipping. Often the aneurysm is held tight by connective tissue and must be freed and isolated from other structures. Additionally, small arteries called perforators must be noted so they are not included in the clip. The clip is held open with a clip applier and placed across the aneurysm neck. Once released, the jaws of the clip close pinching off the aneurysm from the parent artery (Fig. 4). Multiple clips may be used.

Step 5. Check the clip : - The surgeon inspects the clip to make sure it is not narrowing the parent artery or has other arteries in its jaws. The dome of the aneurysm is punctured with a needle to make sure blood is not filling the aneurysm. Intraoperative angiography may be performed to confirm blood flow through the parent artery.

Step 6. Close the craniotomy : - Once the clip is in place, the retractors holding the brain are removed and the dura is closed with sutures. The bone flap is replaced and is secured to the skull with titanium plates and screws. The muscles and skin are sutured back together. A turban-like or soft adhesive dressing will be placed over the incision.

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What Happens After Surgery?

After surgery you'll be taken to the recovery room, where vital signs are monitored as you awake from anesthesia. Then you'll be transferred to the neuroscience intensive care unit (NSICU) for observation and monitoring. Pain medication will be given as needed. You may experience nausea and headache after surgery; medication can control these symptoms.

After 24 to 48 hours, unruptured aneurysm patients are usually transferred to the neurological floor. Monitoring will continue as you increase your activity level. In a few days you'll be released from the hospital and given discharge instructions.

Ruptured aneurysm patients stay in the NSICU for 14 to 21 days and are monitored for signs of vasospasm, which is a narrowing (spasm) of an artery that may occur 3-14 days following a SAH. Signs of vasospasm include arm or leg weakness, confusion, sleepiness, or restlessness

What Are The Risks?

No surgery is without risk. General complications related to brain surgery include infection, allergic reactions to anesthesia, stroke, seizure, and swelling of the brain. Complications specifically related to aneurysm clipping include vasospasm, stroke, seizure, bleeding, and an imperfectly placed clip, which may not completely block off the aneurysm or blocks a normal artery unintentionally.

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