Clip-retraction of the superficial Sylvian vein to enhance visualization in "retractorless" aneurysm surgery.

Abstract

According to microsurgical principles, the access to deep-seated cerebral lesions should be as atraumatic as possible. Temporary brain retraction is acceptable in certain situations and may be indispensable when the view of the lesion is obstructed. The utility of this method is illustrated in a case of a ruptured middle cerebral artery (MCA) aneurysm. Two temporary aneurysm clips were connected by a braided suture, thus forming a band with two points of attachment. The Sylvian fissure was opened in a standard fashion. Using one clip, the adventitia and arachnoid over the superficial Sylvian vein were grasped firmly enough to mobilize the superficial Sylvian vein. The distal clip was then attached to surrounding drapes, thus granting a direct view of the aneurysm in the depth of the fissure. Retraction with spatula was not necessary. Patency of the superficial Sylvian vein was demonstrated using idocyanine green angiography. We present a simple method for minimally traumatic brain retraction using aneurysm clips attached to the adventitia of Sylvian veins and held back by sutures. The use of clips attached to the adventitia of the superficial Sylvian may be of help in retracting the Sylvian fissure. By virtue of enlarging the field of view into the deep Sylvian fissure, it may be of help in performing retractorless aneurysm surgery.