26-2: Craniotomy for Aneurysm Repair

Which of the following symptoms is not typically present in a patient with a ruptured cerebral aneurysm?

a. Meningeal irritation
b. Focal signs of cerebral damage
c. Uniformly clear spinal fluid
d. Bloody spinal fluid

c. Uniformly clear spinal fluid

Where are cerebral aneurysms typically found?

a. At points of bifurcation in the arteries of the circle of Willis
b. In the veins of the brain
c. In the arteries of the spinal cord
d. In the carotid artery only

a. At points of bifurcation in the arteries of the circle of Willis

Where do more than 85% of cerebral aneurysms occur?

a. In the carotid circulation
b. In the vertebrobasilar circulation
c. In the jugular veins
d. In the pulmonary arteries

a. In the carotid circulation

Where do 30% of cerebral aneurysms arise in the carotid circulation?
a. Internal carotid near the origin of the posterior communicating artery
b. Middle cerebral artery
c. Basilar artery
d. External carotid artery

a. Internal carotid near the origin of the posterior communicating artery

What is the goal of surgical treatment for a cerebral aneurysm?
a. To isolate the aneurysm from the parent vessel by placing a clip across the neck of the aneurysm
b. To remove the aneurysm completely
c. To administer medication to reduce swelling
d. To reduce blood flow to the aneurysm

a. To isolate the aneurysm from the parent vessel by placing a clip across the neck of the aneurysm

What material is commonly used to reinforce the sac of an aneurysm if it cannot be clipped?
a. Silicone
b. Polymethyl methacrylate or mesh gauze
c. Stainless steel
d. Teflon

b. Polymethyl methacrylate or mesh gauze

Which of the following may be done if the aneurysm cannot be clipped during surgery?
a. The aneurysm may be drained
b. The sac may be reinforced with synthetic materials or a feeding vessel may be ligated
c. A stent may be placed to prevent rupture
d. The aneurysm is simply monitored with imaging

b. The sac may be reinforced with synthetic materials or a feeding vessel may be ligated

What diagnostic tool reveals the exact size and location of a cerebral aneurysm?
a. MRI
b. CT scan
c. Angiography
d. Ultrasound

c. Angiography

What equipment is specifically used in aneurysm repair?
a. Microsurgical instruments with aneurysm clips and applicators
b. Carotid set for carotid artery exposure
c. Papaverine
d. All of the above

d. All of the above

Which of the following is used for hemorrhage control during aneurysm repair?
a. Papaverine
b. Carotid set for carotid artery exposure
c. Aneurysm clips
d. Microsurgical instruments

b. Carotid set for carotid artery exposure

What is the preoperative preparation for craniotomy for aneurysm repair?
a. Same as for craniotomy
b. Special preparation for aneurysm repair
c. Only fasting required
d. No preparation needed

a. Same as for craniotomy

What is a practical consideration for craniotomy for aneurysm repair?
a. Same as for craniotomy
b. Use of special instruments
c. Specific anesthetic management
d. Postoperative blood transfusions

a. Same as for craniotomy

1-What is the first step in the surgical procedure for craniotomy for aneurysm repair?
a. Sylvian fissure dissection
b. Craniotomy entry
c. Placement of brain spoons
d. Use of bipolar cautery

b. Craniotomy entry

2-Which lobes are separated when the Sylvian fissure is split during aneurysm repair surgery?
a. Frontal and temporal lobes
b. Occipital and temporal lobes
c. Parietal and frontal lobes
d. Cerebellum and brainstem

a. Frontal and temporal lobes (Bipolar Cautery Dissection)

3-What anatomical structures are visualized during craniotomy for aneurysm repair after splitting the Sylvian fissure?
a. Optic nerves and optic chiasma
b. Cerebellum and brainstem
c. Frontal lobes
d. Temporal lobes

a. Optic nerves and optic chiasma

3-What instrument is used to secure the brain during aneurysm repair surgery?
a. Brain spatulas
b. Leyla-Yasargil or Greenberg self-retaining retractor
c. Brain Spoons
d. Neurosurgical clips

b. Leyla-Yasargil or Greenberg self-retaining retractor

4-What instrument is used for the exposure of the aneurysm's feeding vessels and neck during surgery?
a. Operating microscope
b. Leyla-Yasargil retractor
c. Aneurysm clip applier
d. Bipolar cautery

a. Operating microscope

4-What should be ready for loading during aneurysm surgery?
a. Aneurysm clip appliers with temporary aneurysm clips
b. Cottonoid patties
c. Aneurysm clip appliers with permanent aneurysm clips
d. Bone wax

a. Aneurysm clip appliers with temporary aneurysm clips

5-When might a temporary aneurysm clip be used during surgery?
a. If the neck of the aneurysm cannot be visualized for permanent clip placement
b. To monitor brain activity
c. To stabilize the patient’s blood pressure
d. To assist in bone flap repositioning

a. If the neck of the aneurysm cannot be visualized for permanent clip placement

5-Which of the following is a primary use for a temporary aneurysm clip?
a. To occlude the parent vessel in case of rupture
b. To check brain temperature
c. To expose the Sylvian fissure
d. To remove thrombus from the vessel

a. To occlude the parent vessel in case of rupture
Part (A): a clip with a coiled circular handle and sharp straight blades is placed from the superior portion of the neck of the aneurysm. Part (B): A clip with a coiled circular handle and curved blades is placed from the inferior side and around the neck of the aneurysm. Part (C): A clip with a coiled circular handle and curved structure extending with straight blades is placed from the lateral side of the aneurysm, the clip is fastened around the neck of the aneurysm. Part (D): A clip with a coiled circular handle and prongs. The prongs of the clip are on either side of the aneurysm, clasping the neck.

Cerebral aneurysm with clip showing different configurations and types of clip.

5What should the CST have ready during a cerebral aneurysm surgery to prevent vasospasm?
a. Papaverine
b. Heparin
c. Sterile saline
d. Epinephrine

a. Papaverine

6-What is applied across the neck of the aneurysm once the patient's blood pressure has been lowered?
a. Aneurysm clip
b. Temporary clip
c. Suture
d. Intracranial stent

a. Aneurysm clip

6-What is a key consideration when using a permanent aneurysm clip during surgery?
a. It cannot be opened and reused once closed
b. It should be sterilized after use
c. It should be applied in a perpendicular direction
d. It can be adjusted after being closed

a. It cannot be opened and reused once closed

6-When is an aneurysm clip typically applied during aneurysm repair?
a. After the patient’s blood pressure has been lowered
b. Before the aneurysm is exposed
c. Immediately following the incision
d. Before the Sylvian fissure is split

a. After the patient’s blood pressure has been lowered

7-What is checked after the aneurysm clip is applied?
a. Proper positioning and leakage
b. Blood flow to the brain
c. The integrity of the dura
d. The pressure of the surrounding tissues

a. Proper positioning and leakage

7-What procedure may be performed if necessary to check the aneurysm clip placement?
a. Intraoperative angiogram with a C-arm
b. CT scan
c. MRI
d. Ultrasound

a. Intraoperative angiogram with a C-arm

7-How is the blood pressure managed during aneurysm repair after the clip is applied?
a. Slowly raised
b. Lowered to reduce bleeding
c. Maintained at a steady level
d. Gradually increased for better tissue perfusion

a. Slowly raised

8-What step is performed after the aneurysm clip is applied in craniotomy for aneurysm repair?
a. Follow the closure steps for a craniotomy and insertion of a drain
b. Perform a final angiogram
c. Monitor for signs of seizure activity
d. Remove the temporary clips

a. Follow the closure steps for a craniotomy and insertion of a drain

What should be monitored closely in the ICU after aneurysm repair surgery?
a. Intracranial pressure and bleeding
b. Pain levels and sedation
c. Respiratory rate and oxygen levels
d. Renal function and electrolytes

a. Intracranial pressure and bleeding

What is the primary concern during the middle portion of a craniotomy procedure?
a. Soft neural tissue using microscopic instrumentation
b. Bone and cranium manipulation
c. Wound closure and skin preparation
d. Fluid management and irrigation

a. Soft neural tissue using microscopic instrumentation

What should the CST be familiar with when preparing for a craniotomy procedure?
a. Organizing back table and Mayo stand setups for various instrumentation
b. Postoperative care and complications
c. Administering anesthesia during surgery
d. Performing intraoperative angiograms

a. Organizing back table and Mayo stand setups for various instrumentation