Beck, Jürgen

Jaiimsin, Alongkorn

Raabe, Andreas

Seifert, Volker

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LETTER TO THE EDITORUse of a strip-clip technique to maintain transpositionof a vertebral artery in microvascular decompressionsurgeryAndreas Raabe & Alongkorn Jaiimsin & Volker Seifert &Jürgen BeckReceived: 16 August 2011 /Accepted: 21 September 2011 /Published online: 8 October 2011# Springer-Verlag 2011Dear Editor,Microvascular decompression (MVD) has become aneffective treatment of trigeminal [3, 5] or glossopharyngealneuralgia [7, 10] and hemifacial spasm [2, 9]. Duringsurgery, a soft implant is commonly used to relieve thenerve or the medulla from the arterial pulsatile pressure.However, an implant may fail when the offending vessel,such as the vertebral artery (VA) or basilar artery (BA), islarge and ectatic. We report a recently used alternative strip-clip technique that can be easily applied to a large vesselsuch as an ectatic VA.The patient was a 46-year-old man with malignantarterial hypertension, despite having a seven-drug therapy.Magnetic resonance imaging revealed compression of theleft rostral ventrolateral medulla (RVLM) caused by the leftVA. Given these findings and the failed multidrug therapyin this young patient, MVD of the RVLM was proposed asa controversial last resort treatment.The patient underwent MVD via a left-sided far lateralapproach. The VA was exposed at the site of left RVLMcompression and dissected off the brain stem. A 5 × 30-mmstrip of equine collagen sheet (Vostra, Aachen, Germany)was prepared and a small hole was cut into both ends of thestrip. The strip was wrapped around the VA to create asling. The ends were brought together and a straight mini-aneurysm clip (Aesculap, Tuttlingen, Germany) wasthreaded through both holes. The clip was then movedclose to the petrous dura to determine the best position ofthe sling to provide gentle traction on the VA. This positionwas marked. A small dissector was used to create a hole inthe petrous dura at that position. The strip-clip was movedto this position again and the clip was slightly opened toclip the dura with one clip branch in the hole previouslycreated. The position of the VA was checked to make surethat traction on perforating arteries was avoided but themedulla was decompressed from the VA. Once the positionof the clip was correct, the clip was moved into the duralhole and fixed (Fig. 1). At the time of discharge, thehypertension of the patient was controlled by a three-drugtherapy.Repositioning of the VA may be considered as a lastresort treatment for multidrug-resistant, severe, idiopathicarterial hypertension with significant compression of theRVLM [4, 6]. This approach is difficult because of theperforators arising from the VA to the medulla and thetendency of the VA to slip back to the original position.Interposing material between the VA and the medulla maynot provide adequate decompression and result in a severeincrease in arterial blood pressure during surgery. Toovercome these difficulties, we found it useful to create asling that could be wrapped around the VA and adjusted inlength to fit variable distances. Creating a hole in both endsof the strip enables the surgeon to use a conventional clip ora mini-clip to affix the sling to the dura mater as requiredand avoids unnecessary manipulations to maintain distancebetween the VA and RVLM. This technique could also beA. Raabe :V. Seifert : J. BeckDepartment of Neurosurgery, Neurocenter,Johann Wolfgang Goethe University,Frankfurt am Main, GermanyA. JaiimsinDepartment of Surgery, Neurosurgical Division, BangkokMetropolitan Administration Medical College and Vajira Hospital,Bangkok, ThailandA. Raabe (*)Bern University Hospital, Department of Neurosurgery,c/o Publication Office, Susan Wieting,3010 Bern, Switzerlande-mail: susan.wieting@insel.chActa Neurochir (2011) 153:2393–2395DOI 10.1007/s00701-011-1183-2Fig. 1 Schematic drawing (left)and intraoperative photograph(right) illustrating the varioussteps of the strip-clip techniquefor repositioning the VA. Afteropening of the dura, the situsshows the VA compressing theleft RVLM (a). A strip of equinecollagen dura substitute wastrimmed and holes were cut atboth sides (asterisk). The VA iselevated at the site of maximumcompression and the strip wasmoved between the VA and themedulla (b) to wrap around theVA with both holes lateral to theVA. The clip was then threadedinto the holes (c). The cliptightens the sling and a point atthe petrous dura was chosenwhere the VA is pulled 1 mm offthe RVLM. This point wasmarked, and a dissector wasused to create a hole into thepetrous dura. Then the clip withthe sling was moved to thispoint and one branch of the clipwas moved into the dural holeand fixed (d)2394 Acta Neurochir (2011) 153:2393–2395used in other neurovascular compression syndromes causedby the VA where it seems difficult to provide a durablerepositioning of this large artery. Compared with other slingtechniques [1, 8], this method is a straightforward manoeu-vre to achieve a contact-free transposition without anyinterposed additional material.Acknowledgements The authors received editing support for thefinal version from Susan Wieting, Bern University Hospital, Departmentof Neurosurgery, Bern, Switzerland.Financial disclosure No funding was received for this article.Conflicts of interest None.References1. Attabib N, Kaufmann AM (2007) Use of fenestrated aneurysmclips in microvascular decompression surgery. Technical note andcase series. J Neurosurg 106:929–9312. Auger RG, Piepgras DG, Laws ER Jr, Miller RH (1981)Microvascular decompression of the facial nerve for hemifacialspasm: clinical and electrophysiologic observations. Neurology31:346–3503. Barker FG, Jannetta PJ, Bissonette DJ, Jho HD (1997) Trigeminalnumbness and tic relief after microvascular decompression fortypical trigeminal neuralgia. Neurosurgery 40:39–454. Fein JM, Frishman W (1980) Neurogenic hypertension related tovascular compression of the lateral medulla. Neurosurgery 6:615–6225. Jannetta PJ (1967) Arterial compression of the trigeminal nerve atthe pons in patients with trigeminal neuralgia. J Neurosurg 26(Suppl):626. Jannetta PJ, Segal R, Wolfson SK Jr (1985) Neurogenichypertension: etiology and surgical treatment. I. Observations in53 patients. Ann Surg 201:391–3987. Laha RK, Jannetta PJ (1977) Glossopharyngeal neuralgia. JNeurosurg 47:316–3208. Melvill RL, Baxter BL (1996) A tentorial sling in microvasculardecompression for trigeminal neuralgia. Technical note. J Neurosurg84:127–1289. Samii M, Gunther T, Iaconetta G, Muehling M, Vorkapic P, SamiiA (2002) Microvascular decompression to treat hemifacial spasm:long-term results for a consecutive series of 143 patients.Neurosurgery 50:712–71810. Sampson JH, Grossi PM, Asaoka K, Fukushima T (2004)Microvascular decompression for glossopharyngeal neuralgia:long-term effectiveness and complication avoidance. Neurosurgery54:884–889Acta Neurochir (2011) 153:2393–2395 2395

Use of a strip-clip technique to maintain transposition of a vertebral artery in microvascular decompression surgery

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Use of a strip-clip technique to maintain transposition of a vertebral artery in microvascular decompression surgery

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