The authors have no acknowledgments.

注:在执行此过程，获得所有必要的机构批准和患者同意。 1.手术技巧<ol><li>导致患者全身麻醉。 </li><li>将桡动脉血压监测。 </li><li>将病人在手术室表仰卧位。 </li><li>后头部被夹入使用标准技术用于一个翼点开颅梅菲尔德头保持器，与同侧面朝上放置磁头30°-45°朝天花板，除了在该头被放置在60°的前 - 交通动脉瘤要允许跨纵裂更好的可视化。 </li><li>定位颈部中线和翻译前方最大限度颈静脉引流，以防止脑水肿，然后扩展的头部来定位同侧颧骨处的最高点，这允许额叶松弛和埃尔evation从解剖过程中眶顶不使用拉钩的。 </li><li>夹头发，准备标准翼点入头皮切口;使用约一到发际线后面两英寸带。 </li><li>无菌预习皮肤并根据护理标准悬垂手术区。 </li><li>对于一个翼点入路从发际后面头皮的中线与平缓曲线向后和下方朝向耳珠延伸它结束约3mm前向耳屏，并在颧骨的上边缘的水平执行标准弯曲头皮切口。执行此切口向下上述颞线和肌肉筋膜在颞肌的电平的头骨。 </li><li>使用电灼对于头皮止血用的双极型器件。 </li><li>切开颞肌下使用该bovie刀单极电设备的头骨。 </li><li>养肌皮瓣保持连接到颞肌底面头皮现在。鱼钩用于外翻皮瓣后颞肌，从使用单极电和骨膜电梯的组合颅骨升高。 </li><li>使用梅岑鲍姆剪刀肌皮瓣的底面进行了股骨头缺血性平面逆筋膜切开，保持筋膜和subfacsial脂肪垫头皮，以免损伤面神经。 </li><li>固定颞肌向后下方，并揭露翼点入路区域与"明星"鱼钩。 </li><li>保持肌皮瓣湿润湿润纱布的所有组件。 </li><li>钻一个单一时间5毫米毛刺孔在计划的开颅有2mm切削毛刺的最靠后的方面，使得侧切削钻头的脚踏板可被插入到该孔，然后使用侧切割钻头用脚板除去拇指大小（约3×4厘​​米）肾形开颅CENTE周围的翼点入路前方的红色。 </li><li>使用1号潘菲尔德，分开的翼点的所有侧硬脑膜和有一个助理轻轻缩回硬脑膜远离正被钻出，以尽量减少穿透硬脑膜和造成皮层受伤的风险的骨表面。 </li><li>用钻头取出翼点入路:向前，直至眶顶的上级和横向方面光滑，上下扁平骨的外侧皮质表，没有进入轨道，以最大限度地暴露额下;内侧，直到钻眶上裂硬膜暴露并取出小块骨头会干扰曝光内侧使用一个钻头或手持Lempert骨切割设备。确保所有的软组织和骨的表面是优秀的止血已经获得避免鲜血淋漓进入硬膜内空间的大脑解剖和动脉瘤曝光时，使用electrocaurtery和骨蜡可以根据需要，在打开硬脑膜前。 </li><li>轻轻地提升硬脑膜并使用11号手术刀穿透硬脑膜，然后用剪刀硬膜创建与底座的翼点入路一个"C"形开口硬脑膜。对固定轨道的外骨皮质硬脑膜平，而无需多余的硬膜小叶那会近端外侧裂和额下区，否则不起眼的可视化。这可以通过使用4-0 Surgilons缝合钉硬脑膜到头皮进行。 </li></ol> 2.大脑放松<ol><li>给25-50 1g甘露糖醇的骨瓣清除的时间来放松大脑，如果麻醉同意，血压会容忍利尿。 注:这将允许时间发生利尿，并最终将放松大脑，帮助清扫过程中最大限度地提高重力依赖大脑回缩。 </li><li>保持呼气末二氧化碳分压30-35毫米汞柱之间实现小幅hypercapnea。注:这将放心地让大脑放松和马解剖过程中ximize重力相关的脑回缩。 </li><li>撤离脑脊液（CSF）由interoptic，颈光打开蛛网膜蓄水池，以促进大脑的放松，和颈内动脉动眼神经水箱和耐心吸CSF，直到所需的大脑放松已经实现。 注:这通常需要约1分钟;没有腰漏极与需要这种技术，它极大地打开了手术走廊。 </li></ol> 3.外侧裂解剖<ol><li>使手术中的显微镜与瓶口成使用无菌​​技术领域中。同时也带来手术的椅子臂支撑到现场无菌最大限度地双手灵巧和防止外科医生的胳膊和手部疲劳。 注:吹嘴应悬垂，使得外科医生可以移动显微镜用口，同时期待通过目镜件之前进行调整。 </li><li>进行清扫。 注:对于前交通动脉瘤，无外侧裂解剖是必需的，最小的（2-3毫米只有极端的情况下，但是这是一种罕见的发生），以无回直肌切除仅使用额下解剖需要;所有其他前床突上动脉瘤流通场所（包括后交通动脉）要求&lt;1厘米近端Sylivan裂缝剥离，露出床突上颈内动脉，其分支（后交通和脉络膜前动脉），颈内动脉末端，A1和M1起源，以及在近端A2和M 2段远端各自分叉。总外侧裂曝光是硬币大小（1毫升×1厘米），无脑拉钩被用于任何的报告的病例。重力依赖脑松弛足以用于在上面所讨论的区域进行手术夹子结扎所需的软组织结构和脉管系统的优良的曝光。 </li><li>使用双手manipula灰与手术microinstruments轻轻打开蛛网膜走廊，根据需要通过该曝光保持脑组织一旁与仪器手柄或抽吸装置的边缘。 注:高级作者的偏好是使用4-法国Fukishima吸嘴在非惯用手和优势手双极bayonettes为钝性剥离或microscissors为锐性剥离。湿润Telfa条被放置在脑表面上操纵以防止皮质损伤的部位。 Cottonoids常粘在脑表面，并且不能容易地前进更深的切割手术进行，而不会引起轻度皮质损伤。 </li><li>使用喉舌在手术显微镜频繁调整的范围和作为，同时保持双手在该领域需要关注的长度。 </li><li>固定在标准方式的动脉瘤，使用抽吸最常在非优势手保持外科走廊和可视免费的C的SF。 </li><li>经过剪辑的位置，进行术中多普勒动脉瘤圆顶确认流动停止，以及流入和流出的船只，以确认流程，仔细检查动脉瘤颈和家长的船只。我们保留术数字减影血管造影（DSA）为前交通动脉瘤和那些夹住动脉瘤，其中流入，流出，或动脉瘤颈不能完全显现，或者有与手术中多普勒关注。术DSA优于吲哚花青绿（ICG）血管造影，因为当多个动脉瘤夹被用来重建动脉瘤颈，夹子可以阻碍可视化。注意:一旦动脉瘤已经牢固夹住，显微镜从游戏场中去除和灌溉用生理盐水溶液大脑关闭后，以尽量减少性气的量。 </li><li>检查所述夹子用于动脉瘤闭塞的多普勒后，在动脉瘤圆顶是穿孔的机智<html>公顷22克针连接于静脉内管道和一个10毫升注射器和手动抽吸吸确认动脉瘤闭塞。 </li><li> Reapproximate天然硬膜用4-0 surgilon并覆盖有合成硬脑​​膜替代，如果防水密封不能够正确地得到。 </li><li>安全的骨板，每护理标准的金属电镀系统。 </li><li>固定抗天然骨骨瓣平齐的前缘，以避免两者之间的空间，这不会是美容上赏心悦目后组织愈合。 </li><li> Reapproximate颞肌筋膜间断2-0薇乔缝合。固定颞肌的顶部以2-0薇乔线迹到正面金属板到它reapproximate到颞线。 </li><li> Reapproximate使用3-0薇乔缝合帽状，它可以使用钉书钉，尼龙或普理灵关闭头皮以标准方式。扮靓每个医生的喜好无菌绷带。 </li></ol>_title"&gt; 4。治疗后护理<ol><li>治疗后患者承认的重症监护病房，并尽快镇静或全身麻醉逐渐消减足够的话，一般在6小时拔管与护理人员动员。 </li><li>排列的物理治疗和职业治疗，以便评估患者安全出院回家，如果有由护理人员任何问题开始手术后的第一天。 </li><li>燃放时满足条件的患者:疼痛控制，只能口服药物，独立排尿，独立走动，和容忍口头食物摄入量。 </li></ol>

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埃里克·德赛是医生顾问MicroVention公司，Covidien公司的神经血管，Integra生命科学公司。

颅内动脉瘤的手术夹子结扎保持在治疗某些类型的动脉瘤的一个相关和重要的选项，尽管这个作用已被削弱，在过去几年中作为血管内技术变得更安全和更有效。血管内介入治疗已超过手术的脑动脉瘤，但血管内治疗后复发率较高，偶尔需要进行动脉瘤复发从血管内治疗失败后手术治疗，具体的形态使得血管内治疗的风险较高，需要放置支架，以及最近的一些文献回顾累计血管内治疗比手术治疗的风险较高，都保持手术夹子结扎有关动脉瘤的治疗。17 将额下的做法是在1908年首次描述由克劳斯单方面的做法，然后通过修改和花花公子为豪雅脑垂体病变和视神经管。18在1933年，多特用这种方法进行裁剪动脉瘤。19通过这种技术有轻微脑曝光和脑拉钩最少需要广泛进入鞍上区。饰面后来Yasargil修改和使用这种技术来夹前交通动脉瘤。20,21许多其它神经外科医生已经修改该技术由不同的术语描述它与已经用这种方法不仅到达血管，而且前颅底病变。 AL-Mefti和福克斯改装眶上方法来supero，眶外侧暴露。22这延伸眶上开颅手术，包括横向和眶上壁。这种方法被用于轨道和颅底肿瘤以及为复杂的前循环动脉瘤夹闭。在神经外科的进步已反映开颅不仅用于化妆品优点也避免c中的大小和曝光omplications如硬膜外血肿，无意皮质损伤，脑回缩，并暴露于室内空气中的时间。 范林德尔特等报道了一系列的139患者共197动脉瘤是分别通过眶上锁孔剪切处理18在这项研究中没有涉及到暴露并发症报道，只有四个病人削波过程中经历动脉瘤破裂。的破裂是由于动脉瘤夹层或夹应用的结果，而不是由于脑回缩。作者描述了多发性动脉瘤可以安全地夹在相同的步骤，并且对侧动脉瘤可以安全地到达。 Petraglia 等人报道了一系列的28例前交通即分别与通过额下方法裁剪处理动脉瘤。8他们描述这种技术是安全和更少的并发症相比传统的翼点入路。 一些相关的锁孔眶上方法的局限性是:（1）不总是在相同的解剖学位置进行锁孔。小切口开颅手术，需要做好术前的规划与MRI和CT重建描绘动脉瘤取向和骨性结构。以这种方式，切口和开颅需要进行个体化的每个病人的解剖结构。 （2）仪器和光的方向必须在同一平面内，并可能需要特别的剪辑，允许更好的可视化的目标。 （3）有开放额窦，这可能抵消任何化妆品的优势相比，翼点入路的风险较高。23（4）需要一个训练有素的神经外科血管。 在我们的机构，为前夹闭颅内动脉瘤的资深作者（EMD）方法包括拇指大小的翼点入路开颅手术无脑拉钩。使用一个吹口手术显微镜的焦距和视保持恒定双手操纵脑组织的未经拉钩角的连续调整上是重要的。这被认为是侵入性比标准方法少，使许多术后并发症，并提供更快的恢复。我们认为，这反映在较短的术后住院时间和更低的总住院费用，相较于从NIS全国平均水平。 要注意的是在我们的机构治疗的患者床突上动脉瘤是非常重要的。我们使用所描述的削波技术不能治疗内颈动脉的连通段下方动脉瘤，因为前床突的钻孔会需要较大的开颅和近端动脉控制颈动脉切下来。此外，没有在这项研究中治疗动脉瘤被认为是巨大的动脉瘤（&gt; 20毫米）。根据我们的经验，这些较大的动脉瘤一般需要更广泛地接触，使旁路和解剖以查明流入和流出区，并不会与一个微型开颅手术治疗的好。此外，这种小规模的开颅手术也容易允许多个夹子安置在需要的时候提供足够的曝光近端和夹层或夹在放置过程中，准备可能的动脉瘤破裂动脉瘤床突上相关的父动脉远端控制。它避免了使用标准尺寸的瓣开颅手术，以减少皮质表面，可在进近过程中被损坏的任何不必要的暴露。它也最大限度地减少潜在的空间的流体和血液的集合，以在硬膜和硬膜外空间。 然而认识到这一点很重要，这是一个单中心，单外科医生，回顾性研究以比较小的样本大小。治疗不乱美化版，这可能是选择偏倚的可能性。我们试图通过匹配组，在55岁以下的患者只有尽量减少偏差;知道年事已高是一个禁忌未破裂脑动脉瘤夹闭。3然而，由于NIS的限制，我们无法控制的重要混杂因素，如动脉瘤的大小和位置，限制可以得出在我们比较的结论全国平均水平。降低成本和缩短住院时间在我们的机构，相较于全国平均水平，也可部分归因于机构资源。中心处理大量的动脉瘤治疗的病例可能拥有热诚的员工和一套标准化的协议。前瞻性随机多中心试验，其中包括长期随访，复发率的成本，并返回到工作将更好地解决这些限制，并扩大研究的范围。 最后，我们强调的是，这种技术被报道了手术治疗未破裂前床突上循环动脉瘤测量不大于20毫米。较大或动脉瘤破裂，并没有在这项研究中，因为这些动脉瘤常常需要进行搭桥和适当的曝光和蛛网膜下腔出血的情况下，较大的开颅手术评估，更大的开颅手术是因为脑肿胀，去骨瓣减压的潜力，并获得实质内肺叶的出血需要。虽然这已经暴露在低Hunt-Hess分级蛛网膜下腔出血患者在上述地区的中小型前循环动脉瘤被使用，这些数据没有在这里学习，不推荐使用，直到医生已经建立了一定程度的舒适性与手术第一次接触，与未破裂动脉瘤。微创拇指大小的翼点入路开颅允许小型和中型的前床突上动脉瘤流通曝光好秒。此外，最小的无侧裂夹层可以用这种开颅手术前交通动脉瘤的临近时获得的。高级作者已发现这种方法接近两者破裂和未破裂前交通动脉瘤时，特别是那些指向下方和前方，其中所述颈部和流入和流出容器可以容易地鉴定是非常有效的。这个拇指大小的开颅允许以最小的没有解剖外侧裂的Gyrus的腹直肌或切除额下的做法。 我们建议的神经外科医生谁不经常使用这些外科技术，审慎并逐步将这些微创和较少的组织损害腾挪到他们的基于舒适度的方法。从键蛛网膜下腔水箱及恒定双手显微外科技术脑脊液引流避免需要拉钩可引起contusio纳秒，局部静脉梗塞，以及手术后的脑水肿，在牵开器站点。利用这套技术已经给我们的患者住院时间短以较低的成本比全国平均水平。

手术结扎夹已经治疗颅内动脉瘤的中流砥柱，但最近已经由微创腔内技术主要是取代1,2临床试验，包括未破裂颅内动脉瘤的国际学习（ISUIA-1和ISUIA-2），以及国际蛛网膜下腔动脉瘤试验（ISAT）已证明低发病率和死亡率，住院时间长度缩短，并降低整体的费用，与血管内治疗相比手术夹子结扎3 - 5然而，血管内治疗后的较高动脉瘤的复发率，导致了检查的累积风险的患者相比，手术夹子结扎。3,4-外科治疗仍然是动脉瘤治疗的重要方式，特别是对于具有形貌可能难以治疗与血管内装置的前循环动脉瘤。 6 - 8这些微创手术方法可减少住院的长度留，手术并发症，治疗费用，并改善患者的预后。9 在这里，我们提出我们的经验，以微创的方法来使用在一个大型三级脑血管中心进行的前循环动脉瘤翼点入路未破裂颅内动脉瘤手术结扎夹和比较的结果与年龄从全国住院样本数据集相匹配（NIS ）。该手术技术进行审查，包括病人的准备，放松大脑，外侧裂解剖和闭合。术后护理和排放要求也将被概述。

<table border="0" cellpadding="0" cellspacing="0" width="963">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Mayfield Infinity skull clamp</td>
			<td style="width:125px;">Integra</td>
			<td style="width:368px;">A-1114</td>
			<td style="width:64px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Mayfield table attachment</td>
			<td style="width:125px;">Integra</td>
			<td style="width:368px;">A-1018</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">4-French Fukishima suction tip</td>
			<td style="width:125px;">Integra</td>
			<td style="width:368px;">R-8986</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Periosteal elevator (Langenbeck)</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">65-1116</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Metzenbaum scissors</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">36-5023</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Malis dissector, round angled</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">80-1541&#160;</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Penfield dissector, style 1</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">65-1015</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Lempert bone rongeur</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">19-1232</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Malis Irrigation Module</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;">Module 1000</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Bovie monopolar electrocautery device</td>
			<td style="width:125px;">Codman</td>
			<td style="width:368px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Insulated blade for electrocautery device</td>
			<td style="width:125px;">Covidien</td>
			<td style="width:368px;">E1455</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Fish-hook retractors</td>
			<td style="width:125px;">Lone Star</td>
			<td style="width:368px;">3350-8G</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Pneumatic drill</td>
			<td style="width:125px;">Medtronic</td>
			<td style="width:368px;">Midas Rex MR7</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Side-cutting drill</td>
			<td style="width:125px;">Medtronic</td>
			<td style="width:368px;">F2/8TA23</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Fluted legend match head tool</td>
			<td style="width:125px;">Medtronic</td>
			<td style="width:368px;">10MH30</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Surgical scalpel No. 10,11,15</td>
			<td style="width:125px;">Bard-Parker</td>
			<td style="width:368px;">0029064 (No.10), 0018291 (No.11), 0018043 (No.15)</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Intra-operative microscope with mouthpiece</td>
			<td style="width:125px;">Leica</td>
			<td style="width:368px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Microscissors</td>
			<td style="width:125px;">V. Mueller</td>
			<td style="width:368px;">NL3785-034(st), NL3785-035(cvd)</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Rhoton dissector, #2</td>
			<td style="width:125px;">V. Mueller</td>
			<td style="width:368px;">NL3785-002&#160;</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Telfa strips</td>
			<td style="width:125px;">American Surgical</td>
			<td style="width:368px;">#80-09 (1/2x3), #80-04 (1/4x3)</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Aneurysm clip</td>
			<td style="width:125px;">Aesculap</td>
			<td style="width:368px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Raney clip applier</td>
			<td style="width:125px;">Aesculap</td>
			<td style="width:368px;">FF012R</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Synthes Matrix metal plating system</td>
			<td style="width:125px;">Synthes</td>
			<td style="width:368px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Braided absorbable surgical sutures (Vicyrl)&#160;</td>
			<td style="width:125px;">Ethicon</td>
			<td style="width:368px;">J790D (3-0), J743D (4-0)</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Braided nylon nonabsorbable surgical sutures (Nurolon) 4-0</td>
			<td style="width:125px;">Ethicon</td>
			<td style="width:368px;">C584D</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:407px;">Doppler System</td>
			<td style="width:125px;">Mizuho</td>
			<td style="width:368px;">07-150-02</td>
			<td></td>
		</tr>
	</tbody>
</table>

minimally invasive thumb-sized pterional craniotomy for surgical clip ligation of unruptured anterior circulation aneurysms

微创手术方法为颅内动脉瘤夹闭可以减少住院时间，手术并发症，治疗费用长度，改善患者的预后。我们提出我们的经验，在一个大型三级脑血管中心进行的前循环动脉瘤微创翼点入路，并比较结果与来自全国住院样本（NIS）的年龄匹配的数据集。 2008年8月至2012年12月，患者≤55岁22选修瘤剪报由同一双奖学金训练有素的脑/神经外科血管内进行。 1例（4.5％）经历了短暂的术后并发症。 18 22例恢复为后续成像，并有经过22个月的平均持续时间没有复发。在NIS数据库2008至2010年进行搜索，也为年龄≤55岁的患者，取得了1,341住院的手术unrupt结扎夹被保险脑动脉瘤。逗留和住院费用使用微创拇指大小的翼点入路术住院长度在我们的机构几乎NIS的一半（停留时间:3.2比5.7天;住院费用:52779美元与101882美元）。微创拇指大小的翼点入路开颅允许未破裂小型和中型的前床突上循环动脉瘤良好的曝光。从键蛛网膜下腔水箱及恒定双手显微外科技术脑脊液引流避免需要拉钩可在牵开器站点造成挫伤，局部静脉梗塞，以及手术后的脑水肿。利用这套技术已经给我们的患者住院时间短以较低的成本比全国平均水平。

目前，在我们的机构超过150个动脉瘤，每年处理。 2008年8月至2012年12月，采用对病人≤55岁supraclinoidal这个动脉瘤微创拇指大小的翼点入路开颅术22选修瘤剪报由同一双奖学金训练有素的脑血管/血管内，发达国家这种技术的神经外科医生（EMD进行）（ 表1）。这个年龄组被选择作为早期试验显示，手术治疗动脉瘤的患者高于此年龄结果比血管内治疗，因此，55岁以上少数患者用手术夹子结扎在我们的机构处理过的更坏的结果。 只有一名患者（4.5％）接受治疗的右侧MCA动脉瘤经历了手术后的并发症。头部CT扫描获得因右MCA的分布减少左上肢的运动，并透露缺血性改变分支期间夹子结扎或血管痉挛短暂血栓栓塞事件的最一致。患者身体和职业治疗改善，在基线两个月随访。 18 22例恢复为后续成像，并有经过22个月的平均持续时间没有复发。 代表全国平均水平，我们利用2008年全国住院样本（NIS）至2010年的NIS是代表所有住院病人在美国的非联邦医院约20％出院数据库。我们获得NIS数据库从卫生保健研究与质量的医疗成本和利用项目（马里兰州洛克维尔）。可在http://www.hcup-us.ahrq.gov的详细信息，对NIS的设计。 住院未破裂脑动脉瘤夹闭从NIS收集通过交叉匹配的国际分类fication疾病（ICD-9-CM）的诊断代码为未破裂动脉瘤（437.3）的程序代码的脑动脉瘤夹闭（39.51）。用于动脉瘤夹闭的ICD-9-CM代码已被先前研究和验证。10 - 16只有在55岁以下的患者被包括在内，与我们的内部数据集与年龄相匹配的情况。我们排除患者的"蛛网膜下腔出血"（ICD-9-CM 430）和"脑出血"（ICD-9-CM 431）。在比较划过来总住院费，我们假设一个每年3％的通货膨胀率每年为使用和调整收费的分析。 1,341住院未破裂脑动脉瘤手术结扎夹进行鉴定。采用微创拇指大小的翼点入路术的住宿，住院费在我们的机构住院的长度是用曼 - 惠特尼U检验相比，NIS。两在我们的机构相比，全国平均水平（ 表2）显著减少结果的措施。 <table border="0" cellpadding="0" cellspacing="0" ><tbody><tr ><td >年龄，岁</td><td > 47.5（44-52） </td></tr><tr ><td >男</td><td > 4（18％） </td></tr><tr ><td >动脉瘤的最大尺寸，毫米</td><td > 6.3（5.6-9.0） </td></tr><tr ><td >位置</td><td ></td></tr><tr ><td >颈内动脉</td><td > 4（18％） </td></tr><tr ><td >大脑中动脉</td><td > 7（32％） </td></tr><tr ><td >大脑前动脉</td><td > 2（9％） </td></tr><tr ><td >前交通动脉</td><td > 6（27％） </td></tr><tr ><td >后交通动脉</td><td > 3（14％） </td></tr><tr ><td >开颅手术的大小，2毫米</td><td > 1835（1,370-2,133） </td></tr><tr ><td >手术后并发症</td><td&gt; 1（4.5％） </td></tr><tr ><td >随访，病程月</td><td > 22（14-28） </td></tr><tr ><td >循环</td><td > 0（0％*） </td></tr><tr ><td colspan="2" >以中位数的连续变量（intequartile范围） </td></tr><tr ><td >呈现为N分类变量（％） </td><td></td></tr><tr ><td colspan="2" > * 4例患者不适用于后续的成像</td></tr></tbody></table> 表1:内部数据集患者特征 <table border="0" cellpadding="0" cellspacing="0"><tbody><tr height="22"><td height="22" style="height:23px;width:292px;"></td><td style="width:163px;">内部数据集</td><td style="width:171px;"> NIS </td><td style="width:64px;">中P值</td></tr><tr height="22"><td height="22" style="height:23px;width:292px;">年龄，岁</td><td style="width:163px;"> 47.5（44 - 52） </td><td style="width:171px;">47（42 - 52） </td><td style="width:64px;"> 0.561 </td></tr><tr height="22"><td height="22" style="height:23px;width:292px;">住院时间，天</td><td style="width:163px;"> 2（1 - 3） </td><td style="width:171px;"> 4（3 - 6） </td><td style="width:64px;"> &lt;0.001 </td></tr><tr height="22"><td height="22" style="height:23px;width:292px;">医院收费，$ </td><td style="width:163px;"> 49040（42550 - 58767） </td><td style="width:171px;"> 77178（55778 - 121461） </td><td style="width:64px;"> &lt;0.001 </td></tr><tr height="22"><td colspan="2" height="22" style="height:23px;">以中位数的连续变量（四分范围） </td><td></td><td></td></tr></tbody></table> 表2:内部数据集相比，全国住院样本（NIS）

Watch this Scientific Journal Video about Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms at JoVE.com

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

微创拇指大小的翼点入路开颅动脉瘤夹闭已经给我们的患者住院时间短以较低的成本比全国平均水平。

微创拇指大小翼点入开颅未破裂前循环动脉瘤的手术夹子结扎

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

minimally-invasive-thumb-sized-pterional-craniotomy-for-surgical-clip

Nanyang Technological University

Research

JoVE Journal

Medicine

15.4K 次观看.  Crouse Neuroscience Institute. 微创拇指大小的翼点入路开颅动脉瘤夹闭已经给我们的患者住院时间短以较低的成本比全国平均水平。 

视频: Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Minimally Invasive Establishment of Murine Orthotopic Bladder Xenografts

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable cell lines are inoculated either by intravesical instillation (model of nonmuscle invasive growth) or intramural injection into the bladder wall (model of invasive growth). Both procedures are complex and highly time-consuming. Additionally, the superficial model has its shortcomings due to the lack of cell lines that are tumorigenic following instillation. Intramural injection, on the other hand, is marred by the invasiveness of the procedure and the associated morbidity for the host mouse.
With these shortcomings in mind, we modified previous methods to develop a minimally invasive approach for creating orthotopic bladder cancer xenografts. Using ultrasound guidance we have successfully performed percutaneous inoculation of the bladder cancer cell lines UM-UC1, UM-UC3 and UM-UC13 into 50 athymic nude. We have been able to demonstrate that this approach is time efficient, precise and safe. With this technique, initially a space is created under the bladder mucosa with PBS, and tumor cells are then injected into this space in a second step. Tumor growth is monitored at regular intervals with bioluminescence imaging and ultrasound. The average tumor volumes increased steadily in in all but one of our 50 mice over the study period.
In our institution, this novel approach, which allows bladder cancer xenograft inoculation in a minimally-invasive, rapid and highly precise way, has replaced the traditional model.

The established technique to inoculate primary invasive orthotopic bladder cancer xenografts requires laparotomy and mobilization of the bladder. This procedure inflicts significant morbidity on the mice, is technically challenging and time-consuming. We therefore developed a high-precision, percutaneous approach utilizing ultrasound guidance.

微创建立小鼠原位膀胱移植瘤的

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable ...

科研

医学

Minimal Invasive Surgical Procedure of Inducing Myocardial Infarction in Mice

Myocardial infarction still remains the main cause of death in western countries, despite considerable progress in the stent development area in the last decades. For clarification of the underlying mechanisms and the development of new therapeutic strategies, the availability of valid animal models are mandatory. Since we need new insights into pathomechanisms of cardiovascular diseases under in vivo conditions to combat myocardial infarction, the validity of the animal model is a crucial aspect. However, protection of animals are highly relevant in this context. Therefore, we establish a minimally invasive and simple model of myocardial infarction in mice, which assures a high reproducibility and survival rate of animals. Thus, this models fulfils the requirements of the 3R principle (Replacement, Refinement and Reduction) for animal experiments and assure the scientific information needed for further developing of therapeutical strategies for cardiovascular diseases.

A highly reproducible model for myocardial infarction in mice with minimal invasive manipulations is described. The model can be easily performed, resulting in a high reproducibility and survival rate. Thus, the described model will reduce the number of required animals as requested by the 3R principle (Replacement, Refinement and Reduction).

在诱导小鼠心肌梗死的微创手术过程

Myocardial infarction still remains the main cause of death in western countries, despite considerable progress in the stent development area in the last ...

Encapsulation Thermogenic Preadipocytes for Transplantation into Adipose Tissue Depots

Cell encapsulation was developed to entrap viable cells within semi-permeable membranes. The engrafted encapsulated cells can exchange low molecular weight metabolites in tissues of the treated host to achieve long-term survival. The semipermeable membrane allows engrafted encapsulated cells to avoid rejection by the immune system. The encapsulation procedure was designed to enable a controlled release of bioactive compounds, such as insulin, other hormones, and cytokines. Here we describe a method for encapsulation of catabolic cells, which consume lipids for heat production and energy dissipation (thermogenesis) in the intra-abdominal adipose tissue of obese mice. Encapsulation of thermogenic catabolic cells may be potentially applicable to the prevention and treatment of obesity and type 2 diabetes. Another potential application of catabolic cells may include detoxification from alcohols or other toxic metabolites and environmental pollutants.

Here, we present a protocol for encapsulation of catabolic cells, which consume lipids for heat production in intra-abdominal adipose tissue and increase energy dissipation in obese mice.

封装产热前脂肪细胞移植到脂肪组织仓库

Cell encapsulation was developed to entrap viable cells within semi-permeable membranes. The engrafted encapsulated cells can exchange low molecular ...

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Minimally invasive transverse aortic constriction (MTAC) conserves the essentials of regular transverse aortic constriction (TAC) while eliminating the use of a ventilator with tracheal intubation. It proves to be a highly desirable method for high-throughput studies on left ventricular overload, particularly in translational studies.

微创横向主动脉缩窄小鼠

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard ...

An Anatomical Study of Nerves at Risk During Minimally Invasive Hallux Valgus Surgery

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional orientation and localization of structures that are not directly visible to the surgeon. This is especially critical for structures at risk like nerves or blood vessels. Optimization of the handling of cadaveric material and the combination of multiple techniques compensate for the limited availability of adequate specimens. The described protocol combines anatomical plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to help localize relevant structures, such as nerves, arteries, veins and to correctly position the portals during MIS procedures. Depiction of these structures in anatomy textbooks can differ from what is encountered in the surgical field; and for this reason, new anatomical studies with a surgical orientation are needed. However, this is a complex, time-consuming technique requiring specific training. The anatomical references described with the so-called 'clock method' provide the surgeon with an easy and reproducible system to locate the path of the nerves at risk in Hallux Valgus MIS procedures. This model can be extrapolated to many other minimally invasive surgical procedures.

Minimally invasive surgical (MIS) procedures rely on anatomical references to localize structures not directly visible to the surgeon. This manuscript describes a combined method of plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to locate the structures at risk during MIS procedures.

微创拇外翻手术中神经风险的解剖学研究

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional ...

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

内镜下鼻中隔成形术有限双线切除: 间隔偏差微创手术

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

电磁导航经胸结节定位用于微创胸外科手术

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

Absorbent Microbiopsy Sampling and RNA Extraction for Minimally Invasive, Simultaneous Blood and Skin Analysis

Conventional skin biopsy limits the clinical research that involves cosmetically sensitive areas or pediatric applications due to its invasiveness. Here, we describe the protocol for using&#160;an absorbent microneedle-based device, absorbent microbiopsy, for minimally invasive sampling of skin and blood mixture. Our goal is to help facilitate rapid progress in clinical research, the establishment of biomarkers for skin disease and reducing the risk for clinical research participants. In contrast to conventional skin biopsy techniques, the absorbent microbiopsy can be performed within seconds and does not require intensive training due to its simple design. In this report, we describe the use of absorbent microbiopsy, including loading and application, on a&#160;volunteer. Then, we show how to isolate RNA from the absorbed sample. Finally, we demonstrate the use of quantitative reverse transcription PCR (RT-qPCR) to quantify mRNA expression levels of both blood (CD3E and CD19) and skin (KRT14 and TYR). The methods that we describe utilize off the shelf kits and reagents. This protocol offers a minimally invasive approach for simultaneous sampling of skin and blood within the same absorbent microbiopsy matrix. We have found human ethics committees, clinicians and volunteers to be supportive of this approach to dermatological research.

In this article, we demonstrate how the absorbent microbiopsy technique is performed and how the sample can be used for RNA extraction for simple and simultaneous sampling of skin and blood in a minimally invasive manner.

吸收性微活检取样和 rna 提取用于微创同时进行血液和皮肤分析

Conventional skin biopsy limits the clinical research that involves cosmetically sensitive areas or pediatric applications due to its invasiveness. Here, ...

A Pre-clinical Rat Model for the Study of Ischemia-reperfusion Injury in Reconstructive Microsurgery

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many areas of biomedical research due to its cost-effectiveness and its translation to humans. This protocol describes a method to create a preclinical free skin flap model in rats with ischemia-reperfusion injury. The described 3 cm x 6 cm rat free skin flap model is easily obtained after the placement of several vascular ligatures and the section of the vascular pedicle. Then, 8 h after the ischemic insult and completion of the microsurgical anastomosis, the free skin flap develops the tissue damage. These ischemia-reperfusion injury-related damages can be studied in this model, making it a suitable model for evaluating therapeutic agents to address this pathophysiological process. Furthermore, two main monitoring techniques are described in the protocol for the assessment of this animal model: transit-time ultrasound technology and laser speckle contrast analysis.

Here, we describe a pre-clinical animal model for studying the pathophysiology of ischemia-reperfusion injury in reconstructive microsurgery. This free skin flap model based on the superficial caudal epigastric vessels in the rat may also allow for the evaluation of different therapies and compounds to counteract ischemia-reperfusion injury-related damage.

重建显微外科缺血再灌注损伤研究的临床前大鼠模型

Ischemia-reperfusion injury is the main cause of flap failure in reconstructive microsurgery. The rat is the preferred preclinical animal model in many ...

Evaluation of Capnography Sampling Line Compatibility and Accuracy when Used with a Portable Capnography Monitor

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment of end-tidal CO2 (ETCO2), its accuracy is commonly validated using commercial kits composed of a capnography monitor and its matching disposable nasal cannula sampling lines. The purpose of this study was to assess the compatibility and accuracy of cross-paired capnography sampling lines with a single portable bedside capnography monitor. A series of 4 bench tests were performed to evaluate the tensile strength, rise time, ETCO2 accuracy as a function of respiratory rate, and ETCO2 accuracy in the presence of supplemental O2. Each bench test was performed using specialized, validated equipment to allow for a full evaluation of sampling line performance. The 4 bench tests successfully differentiated between sampling lines from different commercial sources and suggested that due to increased rise time and decreased ETCO2 accuracy, not all nasal cannula sampling lines provide reliable clinical data when cross-paired with a commercial capnography monitor. Care should be taken to ensure that any cross-pairing of capnography monitors and disposable sampling lines is fully validated for use across respiratory rates and supplemental O2 flow rates commonly encountered in clinical settings.

The goal of this study was to evaluate the accuracy of capnography sampling lines used in conjunction with a portable bedside capnography monitor. Sampling lines from 7 manufacturers were evaluated for tensile strength, rise time, and ETCO2 accuracy as a function of respiratory rate or supplemental oxygen flow rate.

与便携式刻度学监视器一起使用时，评估卡光采样线兼容性和准确性

Capnography is commonly used to monitor patient&#8217;s ventilatory status. While sidestream capnography has been shown to provide a reliable assessment ...