Neurovascular Surgery Surgical Approaches For Neurovascular Diseases Julius July Download PDF

Full download test bank at ebook textbookfull.
com
Neurovascular Surgery Surgical

Approaches for Neurovascular
CLICK LINK TO DOWLOAD
https://textbookfull.com/product/neurovascula
r-surgery-surgical-approaches-for-
neurovascular-diseases-julius-july/
textbookfull
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
New Horizons in Neurovascular Coupling: A Bridge

Between Brain Circulation and Neural Plasticity 1st
Edition Kazuto Masamoto
https://textbookfull.com/product/new-horizons-in-neurovascular-
coupling-a-bridge-between-brain-circulation-and-neural-
plasticity-1st-edition-kazuto-masamoto/
Atlas of Surgical Approaches for Soft Tissue and

Oncologic Diseases in the Dog and Cat Marije Risselada
https://textbookfull.com/product/atlas-of-surgical-approaches-
for-soft-tissue-and-oncologic-diseases-in-the-dog-and-cat-marije-
risselada/
Dr Pestana s Surgery Notes Top 180 Vignettes for the

Surgical Diseases Kaplan Test Prep 5e Apr 7 2020 _
1506254349 _ Kaplan Medical Test Prep Fifth Edition
Pestana
https://textbookfull.com/product/dr-pestana-s-surgery-notes-
top-180-vignettes-for-the-surgical-diseases-kaplan-test-
prep-5e-apr-7-2020-_-1506254349-_-kaplan-medical-test-prep-fifth-
edition-pestana/
Drug Delivery Challenges and Novel Therapeutic

Approaches for Retinal Diseases Christopher L. Cioffi
https://textbookfull.com/product/drug-delivery-challenges-and-
novel-therapeutic-approaches-for-retinal-diseases-christopher-l-
cioffi/
Abdominal Wall Surgery How Reimbursement Systems Can
Change Surgical Evolution Dalila Patrizia Greco
https://textbookfull.com/product/abdominal-wall-surgery-how-
reimbursement-systems-can-change-surgical-evolution-dalila-
patrizia-greco/
Success in Academic Surgery Developing a Career in

Surgical Education Carla M. Pugh
https://textbookfull.com/product/success-in-academic-surgery-
developing-a-career-in-surgical-education-carla-m-pugh/
Emergency General Surgery, An Issue of Surgical

Clinics, Volume 98-5 Ronald Martin
https://textbookfull.com/product/emergency-general-surgery-an-
issue-of-surgical-clinics-volume-98-5-ronald-martin/
Cell Biology and Translational Medicine Volume 2

Approaches for Diverse Diseases and Conditions Kursad
Turksen
https://textbookfull.com/product/cell-biology-and-translational-
medicine-volume-2-approaches-for-diverse-diseases-and-conditions-
kursad-turksen/
Fundamentals of Orthognathic Surgery and Non Surgical

Facial Aesthetics Third Edition Malcolm Harris (Editor)
https://textbookfull.com/product/fundamentals-of-orthognathic-
surgery-and-non-surgical-facial-aesthetics-third-edition-malcolm-
harris-editor/
Neurovascular
Surgery
Surgical Approaches for
Neurovascular Diseases
Julius July
Eka J. Wahjoepramono
Editors
Neurovascular Surgery
Julius July • Eka J. Wahjoepramono
Editors
Neurovascular Surgery
Surgical Approaches for
Neurovascular Diseases
Editors
Julius July Eka J. Wahjoepramono
Department of Neurosurgery Department of Neurosurgery
Pelita Harapan University Pelita Harapan University
Tangerang Tangerang
Indonesia Indonesia
This book is an open access publication.

ISBN 978-981-10-8949-7 ISBN 978-981-10-8950-3 (eBook)
https://doi.org/10.1007/978-981-10-8950-3
Library of Congress Control Number: 2018956495
© The Editor(s) (if applicable) and The Author(s) 2019

Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons
license and indicate if changes were made.
The images or other third party material in this book are included in the book’s Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the book’s Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly
from the copyright holder.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
Preface
This book is a compilation of the practical details and practices of the key
steps in doing a neurosurgery for residents and young neurosurgeons, which
provides a variety of illustrations of the intraoperative photographs that will
help neurosurgeons gain a better understanding in the neurosurgery field. The
chapters are grouped into three parts. The first part, from Chap. 1 through 10,
is about an approach-based topic which focuses primarily on the commonly
used approach for vascular lesion. The second part, from Chap. 11 through
25, consists of a variety of surgery procedures for specific location of vascu-
lar lesion or specific pathology.
The first two groups provide the expert’s trick on how to avoid complica-
tions during the surgery and some additional expert opinions. The third part,
from Chap. 26 through 32, compiles the miscellaneous information that con-
tains some supportive knowledge, technology improvement, and other
options of treatment modalities. The detailed and step-by-step approach pre-
sented in each chapter with the intraoperative pictures will help provide guid-
ance, especially for many young neurosurgeons who are in the areas with
limited resources.
It is a goal to keep this book simple and practical by providing the strength
of basic surgical anatomy orientation. Each specific pathology or location
requires different approaches that have been addressed in some of the chap-
ters. Every thought and idea shared in the chapters of this book is written by
experts who have been in their fields, practicing for many years. Every con-
tributor represents his or her region’s best practices that have been proven
true based from the neurosurgery results and testimonies they collected and
experienced.
We would like to say many thanks to all the contributors who unselfishly
shared their expertise and time and to the Springer Publishing Co., which
made the publication possible, especially to Dr. Eti Dinesh who encouraged
the editors to get this book published. Our gratitude to all the people who are
involved in the preparation, from the moment this book was conceptualized.
A special thanks to Dr. Megah Indrasari whose support motivated us to
believe in what we see for the future of neurosurgery and to never give up on
our dreams. And to all our friends who journeyed along with us through this
project.
v
vi Preface
May this book serve as a quick and practical reference for many young
neurosurgeons and to those who may need it, in all parts of the world.
Tangerang, Indonesia Julius July

Tangerang, Indonesia Eka J. Wahjoepramono
Contents
Part I Surgical Approaches
1 Pterional Approach�� 3

Sophie Peeters and Julius July
2 Eyebrow Keyhole Approach in Aneurysm Surgery�� 11
Asra Al Fauzi, Nur Setiawan Suroto, and
Abdul Hafid Bajamal
3 Fronto-orbito-zygomatic (FOZ) Approach�� 17
Imad N. Kanaan
4 Lateral Supraorbital Approach�� 23
Juha Hernesniemi, Hugo Andrade-Barazarte, Rosalia Duarte,
Joseph Serrone, and Ferzat Hijazy
5 Interhemispheric Approach�� 29
Alberto Feletti, Dilshod Mamadaliev, Tushit Mewada,
Kei Yamashiro, Yasuhiro Yamada, Tsukasa Kawase,
and Yoko Kato
6 Subtemporal Approach�� 35
Yong Bae Kim and Kyu Sung Lee
7 Lateral Suboccipital Approach (Retrosigmoid)�� 43
Senanur Gulec, Francesca Spedicato, Ferry Senjaya,
and Julius July
8 Transmastoid Approach for Retrolabyrinthine
and Translabyrinthine �� 49
Tetsuro Sameshima
9 Dissection of Extended Middle Fossa and Anterior
Petrosectomy Approach�� 59
Tetsuro Sameshima
10 Basic Endovascular Technique for Aneurysm Coiling �� 79
Harsan
vii
viii Contents
Part II Surgery for Specific Location of Vascular Lesion

or Specific Pathology
11 Surgery of Posterior Communicating Artery Aneurysm �� 87

Julius July
12 Surgery of IC-Anterior Choroidal Aneurysms �� 93
Thomas Kretschmer, Christian Heinen, Julius July, and
Thomas Schmidt
13 Surgery of Paraclinoid Aneurysm�� 105
Naoki Otani, Terushige Toyooka, and Kentaro Mori
14 Surgery of Anterior Communicating Artery Aneurysms�� 117
Yoko Kato, Mohsen Nouri, and Guowei Shu
15 Surgery of Middle Cerebral Artery (MCA) Aneurysm�� 125
Fusao Ikawa
16 Surgery of Posterior Cerebral Artery Aneurysm�� 135
Joseph C. Serrone, Ryan D. Tackla, and Mario Zuccarello
17 Surgery of Upper Basilar Artery Aneurysm �� 141
Kentaro Mori, Terushige Toyooka, and Naoki Otani
18 Surgery of Superior Cerebellar Artery Aneurysm (SCA)�� 149
Miguel A. Arraez, Miguel Dominguez, Cristina
Sanchez-Viguera, Bienvenido Ros, and Guillermo Ibañez
19 Surgery of Posterior Inferior Cerebellar Artery (PICA)
Aneurysm�� 155
Ivan Ng and Julian Han
20 Surgery of Giant Aneurysm�� 163
Petra Wahjoepramono and Eka J. Wahjoepramono
21 Surgery of Posterior Fossa AVM�� 171
Ferzat Hijazy, Mardjono Tjahjadi, Aruma O’shahinan,
Hanna Lehto, Hugo Andrade, Behnam Rezai Jahromi,
Johan Marjamaa, Aki Laakso, Martin Lehecka, and Juha
Hernesniemi
22 Endovascular Coiling of Intracranial Aneurysms�� 185
Naoya Kuwayama
23 Transparent Sheath for Neuroendoscopic Intracerebral
Hematoma Surgery�� 193
Daisuke Suyama, Jun Hiramoto, Kei Yamashiro,
Yasuhiro Yamada, Tsukasa Kawase, and Yoko Kato
24 Surgery of Intracerebral Hemorrhage�� 201
Regunath Kandasamy, Zamzuri Idris, and
Jafri Malin Abdullah
Contents ix
25 Intracranial Dural Arteriovenous Fistula:

Microneurosurgery Basics and Tricks �� 211
Anna Piippo, Mardjono Tjahjadi, and Juha Hernesniemi
Part III The Miscellaneous Chapter
26 Moyamoya Disease, Basic Concepts of Diagnostics,

and Treatment�� 223
Dilshod Mamadaliev, Alberto Feletti, Tushit Mewada,
Kei Yamashiro, Yasuhiro Yamada, Tsukasa Kawase,
and Yoko Kato
27 Flow Arrest for Complex Intracranial Aneurysm
Surgery by Using Adenosine �� 233
Xiangdong Wang, Yasuhiro Yamada, Tsukasa Kawase,
and Yoko Kato
28 Spinal Arteriovenous Malformations �� 239
Antonio López González, Mardjono Tjahjadi,
Andrés Muñoz Nuñez, and Francisco Javier Márquez Rivas
29 Vasospasm Following Aneurysmal Subarachnoid
Hemorrhage�� 249
Eduardo Vieira and Hildo Azevedo-Filho
30 Retractorless Surgery of Vascular Lesions�� 255
Thomas Kretschmer, Christian Heinen, and Thomas Schmidt
31 FLOW 800 for Vascular Surgery�� 269
Yoko Kato, Ittichai Sakarunchai, and Mohsen Nouri
32 Gamma Knife Surgery for AVM�� 275
Lutfi Hendriansyah
Index�� 285
About the Editors
Julius July completed his fellowship in neurovascular surgery at the

Department of Neurosurgery, Fujita Health University Hospital, Toyoake,
Nagoya, Japan in 2003 and in neuro-oncology and skull-base surgery at the
Department of Neurosurgery, Toronto Western Hospital, University of
Toronto, Canada in 2007. He is also a certified International Fellow of the
American Association of Neurological Surgeons (IFAANS), and a member of
the Congress of Neurological Surgeons (CNS), and Asian Congress of
Neurological Surgeons (ACNS).
He is a member of the neuro-oncology and neurovascular committee of
the Indonesian Society of Neurological Surgeons (PERSPEBSI) and vice
treasurer of the Indonesian Society of Neurological Surgeons (PERSPEBSI).
He has published numerous journal articles and books and is an editorial
board member of Medicinus (Medical Journal of Pelita Harapan University),
the Journal of Spine and Neurosurgery, the Indonesian Biomedical Journal,
and the Asian Journal of Neurosurgery. He is currently an associate professor
at Department of Neurosurgery and director of clinical education at the
Medical Faculty of Universitas Pelita Harapan, Tangerang, Indonesia. He is
also a staff neurosurgeon at the Neuroscience Center, Siloam Hospital Lippo
Village. He is involved in teaching and mentoring neurosurgery residents and
medical students. His areas of interest include neurovascular surgery, neuro-
oncology, and neuro-endoscopy surgery.
Eka J. Wahjoepramono is currently a professor, chairman, and dean of the
Medical Faculty of Universitas Pelita Harapan, Tangerang, Indonesia. He is
an active neurosurgeon at the Neuroscience Center, Siloam Hospital Lippo
Village. He is an editorial board member of several national and international
journals and is a widely published author. He is also a member of AANS
(American Association of Neurological Surgeons), vice treasurer of WFNS
World Federation of Neurosurgical Societies, chair of the educational com-
mittee of AASNS (Asian Australasian Society of Neurological Surgeons), the
past president of ACNS (Asian Congress of neurological surgeons), and a
member of neurovascular committee of the Indonesian Society of Neurological
Surgeons (PERSPEBSI).
xi
Contributors
Jafri Malin Abdullah, MD Department of Neurosciences, Centre for

Neurosciences Services and Research, School of Medical Sciences, Universiti
Sains Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia
Hugo Andrade-Barazarte, MD Department of Neurosurgery, Helsinki
University Central Hospital, Helsinki, Finland
Miguel A. Arraez, MD, PhD Department of Neurosurgery, Carlos Haya
University Hospital, Malaga, Spain
Hildo Azevedo-Filho, MD, PhD, MSc, FRCS SN Department of
Neurological Surgery, Hospital da Restauracao, Recife, Brazil
Abdul Hafid Bajamal, MD Department of Neurosurgery, Universitas
Airlangga, Dr. Soetomo General Hospital, Surabaya Neuroscience Institute,
Surabaya, Indonesia
Miguel Dominguez, MD, PhD Department of Neurosurgery, Carlos Haya
Rosalia Duarte, MD Department of Neurosurgery, Helsinki University
Central Hospital, Helsinki, Finland
Asra Al Fauzi, MD Department of Neurosurgery, Universitas Airlangga,
Dr. Soetomo General Hospital, Surabaya Neuroscience Institute, Surabaya,
Indonesia
Alberto Feletti, MD, PhD Department of Neurosurgery, Fujita Health
University, Banbuntane Hotokukai Hospital, Nagoya city, Aichi, Japan
Department of Neurosurgery, NOCSAE Modena Hospital, Modena, Italy
Antonio López González, MD Department of Neurosurgery, Virgen
Macarena and Virgen del Rocío University Hospitals, Seville, Spain
Senanur Gulec Department of Neurosurgery, Faculty of Medicine
Universitas Pelita Harapan (UPH), Neuroscience Centre Siloam Hospital
Lippo Village, Tangerang, Indonesia
Marmara University School of Medicine, Istanbul, Turkey
Julian Han, MD National Neuroscience Institute (NNI), Singapore,
Singapore
xiii
xiv Contributors
Harsan, MD, PhD Department of Neurosurgery, Faculty of Medicine

Christian Heinen, MD Department of Neurosurgery, Evangelisches
Krankenhaus Oldenburg, Oldenburg, Germany
Lutfi Hendriansyah, MD, PhD Gamma Knife Center Indonesia, Siloam
Hospitals Lippo Village, Tangerang, Indonesia
Juha Hernesniemi, MD, PhD Department of Neurosurgery, Helsinki
Ferzat Hijazy, MD Department of Neurosurgery, Helsinki University
Jun Hiramoto, MD Department of Neurosurgery, Fuchu Keijinkai Hospital,
Tokyo, Japan
Guillermo Ibañez, MD Department of Neurosurgery, Carlos Haya
Zamzuri Idris, MD Department of Neurosciences, Centre for Neurosciences
Services and Research, School of Medical Sciences, Universiti Sains
Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia
Fusao Ikawa, MD Department of Neurosurgery, Shimane Prefectural
Central Hospital, Izumo, Japan
Behnam Rezai Jahromi, MB, MD Department of Neurosurgery, Helsinki
Julius July, MD, PhD, MHSc, IFAANS Department of Neurosurgery,
Faculty of Medicine Universitas Pelita Harapan (UPH), Neuroscience Centre
Siloam Hospital Lippo Village, Tangerang, Indonesia
Imad N. Kanaan, MD, FACS, FRCS Department of Neurosciences, King
Faisal Specialist Hospital and Research Center, Alfaisal University, College
of Medicine, Riyadh, Saudi Arabia
Regunath Kandasamy, MD Department of Neurosciences, Centre for
Neurosciences Services and Research, School of Medical Sciences, Universiti
Sains Malaysia Health Campus, Kota Bharu, Kelantan, Malaysia
Yoko Kato, MD, PhD Department of Neurosurgery, Fujita Health University,
Toyoake, Aichi, Japan
Tsukasa Kawase, MD, PhD Department of Neurosurgery, Fujita Health
Yong Bae Kim, MD Department of Neurosurgery, Yonsei University College
of Medicine, Gangnam Severance Hospital, Seoul, South Korea
Thomas Kretschmer, MD, PhD Department of Neurosurgery, Evangelisches
Contributors xv
Naoya Kuwayama, MD, PhD Division of Neuroendovascular Therapy,

Department of Neurosurgery, University of Toyama, Toyama, Japan
Aki Laakso, MD, PhD Department of Neurosurgery, Helsinki University
Kyu Sung Lee, MD Department of Neurosurgery, Yonsei University College
of Medicine, Gangnam Severance Hospital, Seoul, South Korea
Martin Lehecka, MD, PhD Department of Neurosurgery, Helsinki
Hanna Lehto, MD Department of Neurosurgery, Helsinki University
Dilshod Mamadaliev, MD Department of Neurosurgery, Fujita Health
Republican Scientific Center of Neurosurgery, Tashkent, Uzbekistan
Johan Marjamaa, MD, PhD Department of Neurosurgery, Helsinki
Tushit Mewada, MCh Department of Neurosurgery, Fujita Health
G. B. Pant Institute of Post Graduate Medical Education and Research,
New Delhi, India
Kentaro Mori, MD, PhD Department of Neurosurgery, National Defense
Medical College, Tokorozawa, Saitama, Japan
Ivan Ng, MD National Neuroscience Institute (NNI), Singapore, Singapore
Mohsen Nouri, MD Gundishapour Academy of Neuroscience, Ahvaz, Iran
Andrés Muñoz Nuñez, MD Department of Neurosurgery, Virgen Macarena
and Virgen del Rocío University Hospitals, Seville, Spain
Aruma O’shahinan, MD Department of Neurosurgery, Helsinki University
Naoki Otani, MD Department of Neurosurgery, National Defense Medical
College, Tokorozawa, Saitama, Japan
Sophie Peeters, MD Department of Neurosurgery, Faculty of Medicine
Lippo Village, Tangerang, Indonesia,
Department of Neurosurgery, University of California Los Angeles (UCLA),
Los Angeles, CA, USA
Anna Piippo, MD, PhD Department of Neurosurgery, Helsinki University
Francisco Javier Márquez Rivas, MD, PhD Department of Neurosurgery,
Virgen Macarena and Virgen del Rocío University Hospitals, Seville, Spain
xvi Contributors
Bienvenido Ros, MD Department of Neurosurgery, Carlos Haya University

Hospital, Malaga, Spain
Ittichai Sakarunchai, MD Division of Neurosurgery, Department of
Surgery, Faculty of Medicine, Prince of Songkhla University, Songkhla,
Thailand
Tetsuro Sameshima, MD, PhD Department of Neurosurgery, Hamamatsu
University School of Medicine, University Hospital, Hamamatsu city, Japan
Cristina Sanchez-Viguera, MD Department of Neurosurgery, Carlos Haya
Ferry Senjaya, MD Department of Neurosurgery, Faculty of Medicine
Thomas Schmidt, MD Department of Neurosurgery, Evangelisches
Joseph C. Serrone, MD Department of Neurosurgery, Virginia Mason
Medical Center, Seattle, WA, USA
Guowei Shu, MD Department of Neurosurgery, Shuguang Hospital,
Shanghai University of Traditional Chinese Medicine, Shanghai, China
Francesca Spedicato, MD Department of Neurosurgery, Faculty of
Medicine Universitas Pelita Harapan (UPH), Neuroscience Centre Siloam
Hospital Lippo Village, Tangerang, Indonesia
Universita Degli Studi. “A.Moro” School of Medicine, Bari, Italy
Nur Setiawan Suroto, MD Department of Neurosurgery, Universitas
Airlangga, Dr. Soetomo General Hospital, Surabaya Neuroscience Institute,
Surabaya, Indonesia
Daisuke Suyama, MD Department of Neurosurgery, Fuchu Keijinkai
Hospital, Tokyo, Japan
Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai
Hospital, Nagoya city, Aichi, Japan
Ryan D. Tackla, MD Department of Neurosurgery, Virginia Mason Medical
Center, Seattle, WA, USA
Mardjono Tjahjadi, MD Department of Neurosurgery, Helsinki University
Terushige Toyooka, MD Department of Neurosurgery, National Defense
Medical College, Tokorozawa, Saitama, Japan
Eduardo Vieira, MD Department of Neurological Surgery, Hospital da
Restauracao, Recife, Brazil
Eka J. Wahjoepramono, MD, PhD Department of Neurosurgery, Faculty
of Medicine Universitas Pelita Harapan (UPH), Neuroscience Centre Siloam
Hospital Lippo Village, Tangerang, Indonesia
Contributors xvii
Petra Wahjoepramono, MD Department of Neurosurgery, Medical Faculty

of Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, West Java,
Indonesia
Department of Neurosurgery, Faculty of Medicine Universitas Pelita Harapan
(UPH), Neuroscience Centre Siloam Hospital Lippo Village, Tangerang,
Indonesia
Xiangdong Wang, MD Department of Neurosurgery, Fujita Health
Yasuhiro Yamada, MD, PhD Department of Neurosurgery, Fujita Health
Kei Yamashiro, MD Department of Neurosurgery, Fujita Health University,
Banbuntane Hotokukai Hospital, Nagoya city, Aichi, Japan
Mario Zuccarello, MD Department of Neurosurgery, University of
Cincinnati, Cincinnati, OH, USA
Part I
Surgical Approaches
Pterional Approach
1
Sophie Peeters and Julius July
1.1 Introduction 1.2 Steps of the Approach
For years, surgeons have been developing surgi- 1.2.1 Positioning and Preparation
cal approaches attempting to achieve maximal
surgical exposure with minimal brain retraction, Position the patient supine, head fixated with a
advantages found within the frontotemporal or Sugita or Mayfield head holder. Two pins need
pterional approach, first described by Yasargil, to be contralateral at superior temporal line
four decades ago [1–3]. Compared to its prede- right above the temporal muscle, and lastly, the
cessors, this approach allowed for wider fronto- third pin is placed at the ipsilateral mastoid
basal exposure, secondary to more significant (Fig. 1.1).
drilling away sphenoid wing; in addition to that When positioning the head, pay attention to
surgeon could dissect and split Sylvian fissure five movements: (1) traction when moving the
wider [1]. Consequently, it was applicable for head toward the surgeon; (2) lifting the surgi-
clipping of both basilar tip and anterior circula- cal area to a level above the atrium, to avoid
tion aneurysms, with an excellent safety-efficacy impeding venous return; (3) deflection and (4)
profile [1]. Later on, the approach will be modi-
fied and combined with others, and its indications
are only growing in number.
S. Peeters
Department of Neurosurgery,
Faculty of Medicine Universitas Pelita Harapan
(UPH), Neuroscience Centre Siloam Hospital Lippo
Village, Tangerang, Indonesia
Department of Neurosurgery, University of California
Los Angeles (UCLA), Los Angeles, CA, USA
J. July (*) Fig. 1.1 Supine position, head is fixed with Sugita head
Department of Neurosurgery, Faculty of Medicine holder with three pins fixed. The angle of head rotation
Universitas Pelita Harapan (UPH), Neuroscience can be tailored according to tip of exposure that we want
Centre Siloam Hospital Lippo Village, to achieve. Usual angle for pterional approach would be
Tangerang, Indonesia around 30–60° head rotation to the contralateral side
© The Author(s) 2019 3

J. July, E. J. Wahjoepramono (eds.), Neurovascular Surgery,
https://doi.org/10.1007/978-981-10-8950-3_1
4 S. Peeters and J. July
rotation, both related to the surgical indica- 1.2.2 Dissection and Mobilize
tion; and (5) torsion, with the angle between Temporal Muscle
the head, neck, and shoulder, large enough to
give the surgeon a satisfying lateral operating Interfascial splitting at temporal region was first
position [4]. Conditions needing slight deflec- introduce by Yasargil [6]. The challenge of this
tion with rotation 45–60° from vertical line to step is preserving the frontalis nerve and reduc-
the floor include cavernous sinus pathologies ing unwanted cosmetic results after the surgery.
and basal lesions, for example, internal carotid The temporal muscle can be divided into two
(IC)-ophthalmic aneurysm, IC-posterior com- portions: one originating along the superior tem-
municating aneurysm, and IC-choroidal seg- poral line and then inserting to mandibular coro-
ment aneurysm. Contrarily, conditions requiring noid process and the second portion originating
increased deflection with rotation 30–45° from on the temporal squama and inserting onto the
vertical line to the floor include carotid bifurca- mandibular temporal crest [7]. There are also two
tion aneurysm, middle cerebral artery (MCA) layers of fascia that cover this muscle (superficial
aneurysm, anterior communicating aneurysms, and deep). Deep layer protects the vessel supply-
and anterior cerebral artery aneurysm, as well as ing the muscle which consists of anterior, inter-
suprasellar tumors. mediate, and posterior deep temporal arteries, all
The hair is combed with chlorhexidine solu- originating from the maxillary artery. It also pro-
tion (Microshield®) or any detergent solution tects the innervations that are coming from tri-
and subsequently shaved about 2 cm from inci- geminal nerve (temporal and mandible branches)
sion line. The shaved skin is then treated with [7]. The splitting plane through laminae of the
alcohol, getting rid of scalp fat and facilitating temporal fascia is created, protecting the fronto-
sticking of the sterile fields. The incision is temporal branch of the frontal nerve [6]. The
marked with methylene blue or marked with temporal muscle is retracted away from temporal
transofix (Fig. 1.1) after injection of local anes- fossa, thus improving exposure and limiting
thetic with lidocaine 10 mg/mL mixed with unnecessary retraction of the cortex while doing
adrenaline 6.25 μg solution. The injection at pin surgery. Dissect the superficial fascia vertically
site and the incision site provides additional pro- with a scalpel of Metzenbaum scissors starting
tection to pain, and the adrenaline would help to about 2 cm at superior orbital rim to the zygo-
keep the drape clean from the blood loss during matic root, along superior temporal line [7].
incision. Avoid monopolar cauterization to limit the risk of
An arcuate semicoronal frontotemporal skin temporal muscle atrophy. Placing a hook in the
cut is performed starting from the upper edge center may aid the separation by scalpel of the
zygomatic arch, anterior to tragal cartilage. The superficial fascia with the underlying fat plane,
skin cut should preserve the superficial temporal obtaining best identification of the deeper muscle
artery and frontal branch of facial nerve. The part that contains nerves and vessels. Both the
incision extends to the midline of the frontal superficial and fat layers are reflected anterolater-
skull, ideally concealed behind the hairline. The ally over the skin flap. To detach the temporalis
arch of Sugita head holder should be placed for muscle, first use the monopolar (on coagulation
suspension and traction of myocutaneous flaps to to avoid any extra bleeding), and transversally
avoid compression of the eyeball. Finally, incise cut the temporal muscle at its insertion, medially
the skin with knife, and stop the scalp bleeding to zygoma and frontal zygomatic process. Then,
with bipolar, and apply the Raney clips. Proceed use a scalpel to cut the muscle in an anterior to
with subgaleal dissection until the line between posterior motion slightly below the superior tem-
the superior border of orbital rim and tragus dis- poral line. A small portion of the myofascial cuff
sects until leaving anterior one fourth of the tem- is intentionally left at superior temporal line on
poral fascia [5]. Retract the skin flap to anterior, the bone flap for future muscle reconstruction in
and hold it with fish hooks. order to prevent atrophy of the muscle [8, 9].
1 Pterional Approach 5
Secondarily, detach the deep fascia from the skull prominent, may require some rongeuring prior to
using a Cushing’s elevator. To avoid bleeding, elevate the bone flap; the alternative is fracturing
start detaching the muscle flap inferiorly where the bone when elevating the flap.
the muscle is least attached to the bone [9]. These
maneuvers release the fascia temporalis, aponeu-
rosis, temporal muscle, and temporal periosteum 1.2.4 Basal Drilling
from the temporal muscle’s origin. Once
detached, the temporal muscle is retracted inferi- Extradural gentle drilling of greater sphenoid
orly leaving its tendinous attachment intact, wing process, projections of orbital roof, and the
exposing the pterional region. Finally, reflect the rest of temporal squama until exposing the supe-
periosteum cranial to superior temporal line to rior orbital fissure may be necessary for better
the anterior direction. Remember to keep all the access to the basal structures with limited brain
tissue moisture by covering it with wet gauge. retraction and flatter bone ridges [8]. The expo-
sure will be magnified even more with opening of
the cisterns and subsequent drainage of the cere-
1.2.3 Craniotomy brospinal fluid. Some even recommend perform-
ing lumbar spinal CSF drainage and
The craniotomy for this will vary based on surgi- ventriculostomy to get more relax brain for a
cal aim; typically, one or two burr holes are suf- skull base approach. Use dissectors to detach the
ficient, though many surgeons will use three. The dura from orbital roof and part that left on lesser
aim of this craniotomy is more basal exposure as sphenoid wing bone without extending past the
well as generous visibility of the Sylvian fissure. limits of the drilling, to avoid forming extradural
Thus, the goal is to attempt exposure of the infe- dead spaces. Place a spatula, attached to an ortho-
rior frontal, part of the middle frontal, gyrus static retractor, to serve a shield to protect the
superior temporal, and superior part of gyrus dural surface. A cylindrical or round drill is used
middle temporal. The burr holes are performed to remove remaining bony prominences from the
with common drilling system aiming posteriorly outside inward on the orbital roof and the remain-
and inferiorly to avoid penetrating the orbit [9]. ing temporal squama. Next, protect the underly-
The first and most important burr hole, also called ing dura with a spatula, and drill the lesser
“keyhole,” is placed at the meeting point between sphenoid until dural cuff containing the meningo-
zygomatic bone, the superior temporal line, and orbital artery located at the superolateral border
supraorbital edge [9]. Second trepanation is of the superior orbital fissure is visible. Isolate,
located inferiorly in the temporal bone’s squa- coagulate, and section this artery using a scalpel.
mous portion, near the pterion. Lastly, the third The best drill for delicate drilling is diamond
hole, optional but recommended in older patients drill. To relax tension on the dura, if necessary, a
due to their dura sticking to the skull, is made on small incision at the projection of the lateral fis-
the most posterior end of superior temporal line. sure level can allow for cerebrospinal fluid drain-
Use dissectors to detach the dura from the skull. age. After drilling, anchor the dura by stitching it
The Sylvian fissure lies beneath the pterion; thus, (3.0 round silk) at bone edge to avoid collection
the inferior frontal gyrus lies between the pterion of epidural blood during or after the operation.
and the superior temporal line. Use either a Gigli
saw or a craniotome for the craniotomy, as long
as the cut is made along the outer edge of the 1.2.5 Opening the Dura
trepanations and extended frontally, taking care and Exposing the Brain
not to open the frontal sinus. Use a bipolar for-
ceps for hemostasis at low power to prevent more The purpose of incising and retracting the dura is
dural shrinking. Greater sphenoid wing lies deep to keep it smooth when folded back over the bony
between first and second burr holes and, if too surface; dural folds can sometimes hinder visibility.
nicates directly cistern around the carotid. The

posterior part is made up of two clefts—oper-
cula and insular. Insula becomes visible once
the Sylvian fissure’s lateral walls are separated.
It links the temporal lobe with posterior orbital
gyrus through limen insula, a threshold between
the fissure laterally and the carotid cistern medi-
ally. The insula covers up a set of valuable struc-
tures such as internal capsules, external capsule,
extreme capsule, the claustrum, the basal ganglia,
and the thalamus. Typically, the basal cisterns are
opened, prior to the transsylvian dissection, in
order to relax the brain through cerebrospinal fluid
drainage. This allows for a cisternal approach to
Fig. 1.2 The inserted picture shows the opening flap is aneurysms, first presented by Yasargil [1]. The
retracted toward anterior inferior using fish hook and the
C-shape opening of dura with its concave facing the skull
opening of the Sylvian fissure is started near the
base. The brain is slightly tense and red, which is common pars triangularis of the parasylvian inferior fron-
for aneurysmal subarachnoid bleed. This is the case with tal gyrus, where there is the most room between
left M1 bifurcation aneurysm bleed frontal and temporal lobes [4, 9] (Fig. 1.3).
Using microscissors and either a scalpel blade
Use Metzenbaum scissors to incise the dura in a number 11, 25G needle, or diamond knife, the
“C”-shaped manner creating a flap pedunculated superficial portion of Sylvian fissure is cut and
toward the previously roungered greater sphenoi- dissected starting from the frontal part of superfi-
dal wing, improving parasellar visibility. cial Sylvian vein. The latter typically runs later-
The concavity of the incision should be toward ally toward the distal end of the temporal lobe
the orbit and sphenoid that were previously roun- and then drains into the sphenoparietal sinus.
gered or flattened using high-speed drill; the However, in some cases, the superficial Sylvian
pedunculated flap is then retracted over the vein may drain toward the frontal Sylvian vein
greater sphenoidal wing remains (Fig. 1.2). This and finally into the superior sagittal sinus, justify-
maneuver will exposes the inferior frontal gyrus, ing a dissection lateral of the superficial Sylvian
the superior temporal gyrus, the middle temporal vein. Relevant anatomical structures identifiable
gyrus, and most importantly the Sylvian fissure. at this stage are ICA, MCA, ACA, and the optic
nerve. It is very important to have a good dissec-
1.2.6 Splitting Sylvian Fissure
Sylvian fissure can be divided into superficial

and a deep part [4]. The stem of the superficial
part extends medial to the semilunar gyrus of the
uncus between inferior frontal lobe and pole of
temporal lobe until lateral portion of sphenoid
wing. The stem then split into anterior ascend-
ing branches, anterior horizontal branches, and
posterior branches. The deeper part of the lateral
fissure divides into an anterior part (sphenoidal)
and posterior part (operculoinsular). Anterior
part is the narrow space between frontal and tem- Fig. 1.3 The pars triangularis of the parasylvian inferior
poral, located behind sphenoid ridge; it commu- frontal gyrus (*), F frontal, T temporal, II optic nerve
Fig. 1.4 The case of M1 bifurcation aneurysm. (1) The dissection allows surgeon to expose the M1, M2, and
aneurysm was identified, but it’s not well exposed yet, and branches. (3) Avoiding the branches and putting the clip
it’s necessary to continue dissection to identify all the sur- on the aneurysm neck. (4) Expose the legs of the clip, and
rounding, especially to find the parent artery in case the confirm the aneurysm is well clipped (R rupture site)
surgeon needs temporary occlusion. (2) Sylvian fissure
tion of Sylvian fissure for certain cases, such as tery and sponge tamponade methods. After closing
MCA aneurysm (Fig. 1.4). the dura until watertight, the bone flap is reposi-
Though the gyrus rectus sometimes obscures tioned and secured with miniplates. The burr hole
the view of the AcomA complex, its resection is area could be covered with a titanium clamp, or the
rarely indicated (Fig. 1.5). This approach grants other options are to fill the hole with bone dust and
access to cistern around olfactory, cistern around make sure that it’s covered well with periosteum.
carotid artery, chiasmatic cistern, sphenoid part The periosteum is very important for bone healing
of lateral fissure, cistern in front of lamina termi- and remodeling to the normal appearance. The tem-
nalis, interpeduncular cistern, ambient cistern, poral muscle flap is placed where it belongs, and the
and crural cistern, which can be attained by temporal muscle is re-sutured to the remaining myo-
resection of anteromedial segment of uncus. fascial cuff on the skull, while the reflected fascia is
sutured to the fascia-periosteum complex. Finally,
the fascial incision and the scalp incision are closed
1.2.7 Closing in the usual manner. The choice of an extradural sub-
galeal closed suction drain should enhance the heal-
When closing, focus on preventing any potential epi- ing and reduce fluid collections under the flap [10].
dural blood collections and attempt to avoid any The classical pterional approach is attractive
major surgical cosmetic defects. Hemostasis must and widely used for many reasons, including
be attained prior to fascial closure, with electrocau- smaller size craniotomy yet still allowing a wide
Fig. 1.5 The case of Acom aneurysm rupture, with left (Gyr). (3) Exposing the AcomA complex with the aneu-
pterional approach. (1) The gyrus rectus obscures the rysm between the both A2. (4) Clipping with ring clip to
AcomA complex. (2) Partial resection of gyrus rectus spare the A2 on the ipsilateral side
frontobasal exposure and rapid access to basal cis- was also used for the removal of tumors and
terns and the circle of Willis, without requiring other vascular malformations found in cavern-
extensive brain retraction. The approach limits ous sinus area but also sella, parasellar, temporal,
unnecessary frontal and temporal lobes exposure. subfrontal, and anterior and anterolateral mid-
It also prevents risk of injury to the optic radiations brain regions. Examples of lesions successfully
or uncinate fasciculus, thus avoiding postoperative treated through this approach include aneurysms,
visual field deficits and aphasia, in the context of olfactory groove meningiomas, cavernomas of
temporal lesion removal [11]. On a cosmetic level, the anterior mesiotemporal region, temporal horn
the pterional approach was favorable for its good tumors, and a clival chordoma. It’s still one of
skin incision behind the hairline, appropriate size the most commonly used approaches in neuro-
bone flap, and the osteoplastic craniotomy prevent- surgery practice.
ing some of the postoperative temporalis atrophy.
1.4 Limitations of the Approach

1.3 Indications of the Approach
The main factors to be considered when selecting
Initially, the approach was suggested for most of the right extent of exposure required are compart-
microsurgical approach for cerebral aneurysms ment that need to be exposed and of course the
in the whole circle of Willis, particularly in the location and size of aneurysm. The main issues
anterior circulation. Later, the pterional approach regarding the pterional approach are obstruc-
tion of the operator’s visualization by the basal dysfunction [12]. The aim of this two-layer flap is
structures, such as orbital roof, sphenoidal ridge, maximizing visibility at the expense of severe
frontal and temporal lobes, and ICA, and tem- retraction of the temporalis muscle. On the other
poral muscle. Sometimes surgeon need to work hand, the myocutaneous flap has considerably
at a deep and narrow naturally available space less risk for facial nerve injury since temporal
between the carotid artery and optic or oculo- muscle is lifted up with scalp in a one-layer flap
motor nerves [1]. Hence, though the indications [5, 13]. However, this myocutaneous flap is at the
for a pterional approach are numerous and it is detriment of worse exposure secondary to the
a widely applicable technique, it is not with- bulkiness of the temporalis muscle [6]. Kim and
out limitations, typically exposure-related. The Delashaw propose an osteomyoplastic monobloc
pterional approach is now often modified by or technique in order to prevent both cosmetic and
combined with the following approaches, tem- functional undesirable outcomes [14]. The proce-
poropolar, pretemporal, cranioorbitozygomatic dure spares the temporalis muscle and the basal
(middle cranial fossa lesions or upper clivus, bone. It involves dissecting a subperiosteal
upper basilar complex), and lateral supraorbital, detachment below the temporal separating it
in order to obtain the optimal diameter and angle from the underlying bone while maintaining the
of exposure for the pathology being treated. For muscle’s attachment to superior temporal line
example, if clipping an aneurysm of the posterior and temporal squama. This is followed by the
circulation (i.e., basilar tip aneurysm), the sur- creation of a keyhole 2 cm posterior to pterion at
gery may have to include removal of the anterior the Sylvian fissure line. Final step consists of
plus or minus the posterior clinoid processes for roungering part of the sphenoid wing allowing its
better visibility; or in order to have better access removal with the pterion in one piece, along with
to the parasellar region, reshaping of the zygo- the bone flap.
matic complex may be helpful [7]. Additionally, Even though most concerns of scalp deformi-
ipsilateral vessels and the gyrus rectus can some- ties (temporal depression, skin indentation)
times hinder ideal exposure of the AcomA com- linked to craniotomies have decreased since the
plex and the contralateral vessels in a pterional introduction of miniplating systems and burr hole
approach; the orbitopterional approach is a great covers, the pterional approach remains prone to
alternative. If a more inferior temporal view is it, especially surrounding the keyhole, due to the
required, removal of the zygomatic arch may be complex curvature of the circumferential bone.
considered. Moscovici et al. suggested that a craniotomy
without the classical MacCarty keyhole leads to
superior aesthetic outcomes with minimal bone
1.5 Complications and How loss [15]. Their approach involves delicate sphe-
to Avoid noid ridge drilling in a plane parallel to the skull
base, thus no longer requiring expansion of the
The main complications that can be expected bony window basally.
from this approach are aneurysmal intraoperative
rupture, epidural or subdural hematoma, infec-
tion, ischemic events, early or late rebleeding, References
temporal muscle atrophy and/or dysfunction, and 1. Yasargil MG, et al. Microsurgical pterional approach to
lastly, cosmetic cranial defects. aneurysms of the basilar bifurcation. Surg. Neurology.
The interfascial flap dieresis technique from 1976;6:83–91.
the original pterional approach, as described by 2. Weil AG, Robert T, Alsaiari S, Obaid S, Bojanowski
MW. Using the trans-lamina terminalis route via a
Yasargil, was found to be associated with more pterional approach to resect a retrochiasmatic cranio-
prevalent, worse, and longer-lasting palsy of pharyngioma involving the third ventricle. Neurosurg
frontotemporal facial nerve branches, temporalis Focus. 2016;40 Video Suppl 1, 1.
muscle atrophy, and temporomandibularis joint
3. Tayebi Meybodi A, Benet A, Lawton MT. Micro- 9. Olivas A, Garcia L. 3D neurosurgical approaches.
surgical clipping of bilateral superior hypophyseal 2011:1.
artery aneurysms through unilateral pterional crani- 10. Choi SY, et al. Necessity of surgical site closed suc-
otomy: 3-dimensional operative video. Neurosurgery. tion drain for pterional craniotomy. J Cerebrovasc
2016;12(2):193. Endovasc Neurosurg. 2015;17:194–202.
4. Chaddad-Neto F, et al. The pterional craniotomy: tips 11. Campero A, et al. Pterional transsylvian-transinsular
and tricks. Arq Neuropsiquiatr. 2012;70:727–32. approach in three cavernomas of the left anterior
5. Miyazawa T. Less invasive reconstruction of the mesiotemporal region. Clin Neurol Neurosurg.
temporalis muscle for pterional craniotomy: modified 2015;130:14–9.
procedures. Surg Neurol. 1998;50:347–51; discus- 12. de Andrade Júnior FC, de Andrade FC, de Araujo
sion 351. Filho CM, Carcagnolo Filho J. Dysfunction of the
6. Yaşargil MG, Reichman MV, Kubik S. Preservation temporalis muscle after pterional craniotomy for
of the frontotemporal branch of the facial nerve intracranial aneurysms. Comparative, prospective and
using the interfascial temporalis flap for pterional randomized study of one flap versus two flaps dier-
craniotomy. Technical article. J Neurosurg. 1987;67: esis. Arq Neuropsiquiatr. 1998;56:200–5.
463–6. 13. Spetzler RF, Lee KS. Reconstruction of the tempo-
7. Altay T, Couldwell WT. The frontotemporal ralis muscle for the pterional craniotomy. Technical
(pterional) approach: an historical perspective. note. J Neurosurg. 1990;73:636–7.
Neurosurgery. 2012;71:481–91; discussion 491–492 14. Kim E, Delashaw JB. Osteoplastic pterional craniot-
8. Andaluz N, Van Loveren HR, Keller JT, Zuccarello omy revisited. Neurosurgery. 2011;68:125–9; discus-
M. Anatomic and clinical study of the orbitopterional sion 129.
approach to anterior communicating artery aneu- 15. Moscovici S, Mizrahi CJ, Margolin E, Spektor
rysms. Neurosurgery. 2003;52:1140–8; discussion S. Modified pterional craniotomy without ‘MacCarty
1148–1149. keyhole’. J Clin Neurosci. 2016;24:135–7.
Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in
any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license and indicate if changes were made.
The images or other third party material in this chapter are included in the chapter’s Creative Commons license,
unless indicated otherwise in a credit line to the material. If material is not included in the chapter’s Creative Commons
license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to
obtain permission directly from the copyright holder.
Eyebrow Keyhole Approach
in Aneurysm Surgery
2
Asra Al Fauzi, Nur Setiawan Suroto,
and Abdul Hafid Bajamal
2.1 Basic Consept 2.2 Preoperative Planning
The concept of keyhole neurosurgery is not only The planning and execution of the approach
to perform small incision and reduce the crani- play a critical role in performing this keyhole
otomy size for the sake of a small opening as we surgery. The smaller the craniotomy, the greater
called “keyhole,” but it is rather to make “mini- the need for precise planning and self-made
mum craniotomy” required to access deep intra- completion of the approach because the corridor
cranial lesions at the end of the route. Standard of surgical dissection cannot be changed during
craniotomy forms a “funnel-shaped surgical the procedure.
corridor” to reach deeper area of the brain. In It is necessary to have preoperative consider-
contrast, keyhole mini craniotomy forms a ation about the size and aneurysm dome projec-
“reverse funnel-shaped surgical corridor” that tion, aneurysm location, perforating arteries,
provides adequate working space through a surrounding important structures, and how to plan
small incision and bone window to reach the tar- the bone flap. Using excellent diagnostic facilities
get. The concept of this approach is that the of CT, MRI, and digital subtraction angiography
deep area of the brain can be accessed through (DSA), one has today the possibility to demon-
smaller craniotomy since the superficial optical strate small details and specific anatomical orien-
field is widened if the size of craniotomy is big- tation of the lesion related with surgical planning.
ger (Fig. 2.1). In our experience, preoperative planning for eye-
Intracranial aneurysm surgery using eyebrow keyhole surgery is could be mainly by using
brow keyhole approach has been reported by and rely on 3D CT angiography (3D-CTA). The
Van Lindert and Perneczky in 1998, and since 3D reconstruction images maybe able to shows
then, this approach has been accepted as mini- from the skin, then skull, cerebral arteries and
mally invasive approach for aneurysm clipping veins, including size and shape of the aneurysm.
surgery in addition to the existing standard The preoperative planning of the keyhole crani-
approach. otomy can be simulated with 3D-CTA (Fig. 2.2).
A. Al Fauzi (*) · N. S. Suroto · A. H. Bajamal

Department of Neurosurgery,
Universitas Airlangga, Dr. Soetomo General Hospital,
Surabaya Neuroscience Institute, Surabaya, Indonesia
© The Author(s) 2019 11

J. July, E. J. Wahjoepramono (eds.), Neurovascular Surgery,
https://doi.org/10.1007/978-981-10-8950-3_2
12 A. Al Fauzi et al.
a b
Fig. 2.1 Concept of surgical corridors in keyhole craniotomy. (a) Keyhole craniotomy with “reverse funnel-shaped”
corridor, (b) macrocraniotomy with “funnel-shaped” corridor
a b
Fig. 2.2 Preoperative planning with 3D CTA images tionship to the aneurysm are well visualized. (b) The
showing the skull, cerebral arteries, and aneurysm pathol- supraorbital craniotomy with the lesion is prepared at vari-
ogy. (a) The supraorbital keyhole craniotomy and its rela- ous angles to have an optimal microsurgical visualization
2.3 Step of the Approach anesthetized, the patient head is positioned in

supine with head holder, and the head is higher
2.3.1 Positioning and Preparation up approximately 15° to facilitate venous drain-
age. A slightly chin-up position is preferable
The surgeon must plan and perform the proper to support the frontal lobe that will slightly fall
positioning of the patient by himself. Self-made down according to the gravity force. The degree
preparation and positioning are essential for cre- of head rotation should be determined by preop-
ating keyhole craniotomies. After the patient is erative 3D simulation, but generally the head is
2 Eyebrow Keyhole Approach in Aneurysm Surgery 13
a b
Fig. 2.3 Supine positioning of the patient, slightly with soft cushion is used for a brief preparation; the use of
extended and the head is turned to contralateral, and head fixation clamp is not necessary
depend on aneurysm location. In most cases, the headrest
rotated between 15° and 45° toward the contra- subcutaneously to obtain optimal exposure to sur-
lateral side, determined by the location and dome rounding muscles. We could clearly identify the
projection of aneurysm. The placement of lumbar frontal, orbicularis oculi and temporal muscles.
drain or extraventricular drainage also allows for After dividing the muscular layers gently, we
brain relaxation specially in ruptured aneurysm have to identify pericranium at supraorbital edge,
case with brain edema. and it is cut perpendicularly following superior
Frontal anatomic landmarks should be pretemporal line to get good bone exposure.
cisely identified, including the foramen supraor- Skin flaps should be gently retracted with
bital, superior temporal line, orbital rim, and three or four temporary stiches at each upper and
zygomatic arch, then drawing the skin incision lower side of the flaps. The frontal muscle should
plan on the skin (Fig. 2.3). be retracted upward, and the temporal muscle is
detached gently from the attachment and retracted
laterally to expose ipsilateral temporal line, and
2.3.2 Skin Cut then keyhole area is exposed. Gentle detachment
and pulling of the muscle are important to pre-
The skin is cut according to the preoperative vent local postoperative hematoma (Fig. 2.4).
planning and anatomical orientation. The skin
is cut at lateral two-thirds of the eyebrow, from
supraorbital notch to the lateral part, sometimes 2.3.3 ini Craniotomy and Dural
M
extending few millimeters to the temporal line. Incision
To achieve a good cosmetic appearance, the inci-
sion should follow the orbital rim, in the hair line. Making a single frontobasal burr hole at the fronto-
It is advisable not to overuse bipolar coagulation zygomatic point just behind the temporal line by
to avoid damaging hair follicles and surrounding using high-speed drill. The placement and direction
tissues. After skin incision, skin flap is dissected of the drilling procedure should be in correct man-
14 A. Al Fauzi et al.
flap is reflected basally and fixed downward with

three or four sutures so that dural window is
formed in optimal opening following craniotomy
corridor (Fig. 2.6).
2.3.4 Intradural Dissection
After opening the dura, the first-step maneuver

is to gently remove sufficient cerebrospinal
fluid by opening the arachnoid membrane
Fig. 2.4 Skin cut from the lateral border of supraorbital
through the chiasmatic and carotid cistern or
notch and extending a few millimeters from the eyebrow
line to reach the temporal line furthermore to Sylvian fissure. Ventricular
puncture and drainage sometimes may be
needed in case of brain edema; the authors only
use the lumbar spinal drain for very selective
cases. With adequate drainage of CSF (cerebro-
spinal fluid), the brain becomes relaxed, then a
brain spatula is put in the frontal lobe, and the
purpose is to protect the cortex and not to retract
the cortex. With this efficient and adequate sur-
gical corridor, we can get to the aneurysm pre-
cisely and avoid extensive cortical retraction
(Fig. 2.7).
2.3.5 losure and Bone Flap

C
Fig. 2.5 Supraorbital keyhole craniotomy with a width Replacement
of 25–30 mm and a height of 15–25 mm
After the intracranial procedure is performed,
ner. Wrong direction during drilling can cause the the next step is filling the intradural space with
drill going into the orbit, while we actually want it warm normal saline. Close the dura with water-
to go to the anterior frontal floor. The craniotomy tight and interrupted sutures, and then make
flap is then performed with high-speed craniotomy, sure that any defects are well repaired. If the
starting from lateral orbital rim and following the frontal sinus opened during the surgery, it is a
orbital rim to medial, as long as 25–30 mm, then must to seal off the frontal sinus to avoid post-
curving cranially about 15–25 mm, and cutting operative infection. Bone flap is placed back,
back to the burr hole site, thus creating a small bone and hold it with mini plates and be careful not to
flap. An important point is the bone cut should be penetrate frontal sinus by the screws. Authors
very close and approaching orbital roof and if nec- prefer using three mini plate fixations at medial,
essary additional drilling to make any prominence lateral, and upper part of craniotomy to make
at the frontal floor totally flat. This may provide a sure a strong fixation to prevent postoperative
few millimeters more exposure and avoid the bony deformity. Reapproximate the temporal muscle
prominence to obstruct surgical visualization and to zygoma by one or two sutures. After final
facilitate optimal microsurgical maneuvers using hemostasis control, reapproximate the subcuta-
microscope and microinstruments (Fig. 2.5). neous layer by interrupted sutures; then the skin
Opening the dura with semicircular shape and is also closed by interrupted sutures in the eye-
the base parallel along the orbital rim. The dura brow (Fig. 2.8).
2 Eyebrow Keyhole Approach in Aneurysm Surgery 15
a b
Fig. 2.6 (a) Opening the dura in a curved fashion toward the frontal base, (b) optimal surgical corridor to the skull base
after dural opening
a b
Fig. 2.7 (a) Intradural dissection and securing the aneurysm using microinstruments, (b) clipping procedure
1. Temporary or permanent supraorbital hypes-

thesia. In eyebrow keyhole craniotomy, the
surgical field is very narrow, and medially the
surgical field is limited by supraorbital notch
that contains supraorbital nerve. Perioperative
anatomical landmark should be prepared pre-
cisely to avoid damaging these structures.
Certainly, keeping a distance of the craniot-
omy site at least 5–10 mm lateral to the orbital
notch can reduce the risk of supraorbital nerve
injury. Sometimes stretching the nerve during
surgery is unavoidable, but preserving the
nerve continuity will provide good chance to
Fig. 2.8 The skin is closed with interrupted suture to have functional recovery after surgery.
control the skin tension for a good cosmetic result 2. Frontal deformity. The frontobasal burr hole
needs to be placed behind the temporal line
after retracting the temporal muscle laterally.
2.4 Complications and How The burr hole site will be covered with the
to Avoid muscle to prevent deformity in this area.
Proper repositioning of the bone flap is also an
There are some complications that could be important step to prevent frontal deformity for
occurred associated with surgical technique in a better cosmetic result. Bone flap should be
eyebrow keyhole approach. fixed frontally and medially without any bony
Another random document with
no related content on Scribd:
to good books and good horses, pursuits which met the approval of
his father-in-law as being the “tastes of a gentleman.”
John Fenley did not show his usual foresight, certainly, in
encouraging Roderick to be in the business and not of it; but then he
confidently expected to live to settle up all his own affairs, and turn
his large fortune into a shape in which it would be more easily
managed than in its primitive form of timber lands and sawmills. No
one could have anticipated his death, which occurred in the prime of
his active life, some five years after his daughter’s marriage.
Even then his son-in-law hardly took the position expected of him.
His long habit of standing aside was not easily overcome, and Mrs.
Le Garde, who had a taste for affairs, and Mr. Rogers, her father’s
private secretary, had actually more to do with certain important
transactions than the nominal head of the business.
One of these transactions was as follows:
“Mrs. Le Garde,” said Mr. Rogers, being shown into the library one
chilly afternoon in early October, “Macomb has cabled from Vienna
to his agent here to close with us for that tract of Michigan timber,
paying the price agreed upon for cash. I have had the papers ready
for some time, and they only want signing. If you can come down
town at once——”
Virginia looked down at her tea-gown, and then at the cheerful
little fire on the hearth, and her novel lying face downward on the
easiest chair.
“Won’t to-morrow morning do as well?” she asked, languidly.
“If you will permit me to say so, by no means, Mrs. Le Garde,” said
Mr. Rogers, suavely.
Something in his manner attracted her attention.
“Why not?” she demanded.
Mr. Rogers looked at the fire for a moment before replying. “You
wish to realize upon the land, you see,” he observed, vaguely. “The
cablegram was received this morning. Macomb’s agent has no
choice but to act on it now. By to-morrow, or next day at the farthest,
there may be reasons apparent which would justify him in declaring
the deal off. It is worth your while, and it should be made worth
mine,” said Mr. Rogers, leaning upon the words, “to see that the
matter is settled this afternoon. I have private advices that forest fires
have started in northern Michigan—ah—somewhat in this vicinity,
and their spread is greatly to be feared. I have not mentioned this to
Mr. Le Garde.”
Mrs. Le Garde hesitated a moment. It would be charitable to
suppose that she did not understand the situation so lightly sketched
in, but I am afraid she did. Mr. Rogers did not raise his eyes.
“Oh, well,” she said, carelessly, “to-day or to-morrow, it doesn’t
signify. If you will have a notary and Macomb’s agent at Mr. Le
Garde’s office in half an hour, Mr. Rogers, I will be there.”
So it was that the papers were executed and payment made that
afternoon. The next day but one, “Forest Fires. Danger to Lumber
Interests in Michigan,” was a prominent head-line in the morning
papers.
When Macomb came home from Vienna to look after his own
affairs a month later he found himself the owner of a diminished
bank account and some hundreds of acres of smoking pine-stumps.
He made a trip to northern Michigan to survey these latter
possessions, and while there succeeded in securing some
interesting statements which it pleased him to call “facts.” Armed with
these, he went to Roderick Le Garde, and laid his case before him.
“First of all, I want to say that I have always thought you an honest
man, Le Garde,” he observed, “and I wish to say that I am bringing
no personal accusations, though the case looks black for you. But I
know your man Rogers is a d——d scoundrel, though I fail to see
how the sale could profit him, apart from its advantages to you. But
you will see I have proof that he was well-informed on the day the
transfer took place that that tract of timber was already on fire in a
dozen places, and nothing on earth could save it from destruction. I
call that obtaining money under false pretences, and I warn you if
you don’t desire to repurchase the entire tract at the price I paid for
it, that I propose to see at once what the courts will call it.”
“Much obliged for your good opinion of me,” said Le Garde, dryly.
“I have perfect confidence in Rogers”—this was not strictly true, but
Roderick was angry—“and none at all in your so-called ‘proofs.’ I
shall do a little investigating for myself. If I find, as I believe, that
Rogers had no other information in the matter than I myself
possessed, and that you have met with your losses only in the
ordinary course of events, you may bring as many suits as you like,
and rest assured that the Fenley estate will fight them to the last
dollar. If it is otherwise—but nothing else is possible! Good-morning,
sir.”
III
“Virginia! Do you mean that Rogers actually approached you in the
matter?”
Mrs. Le Garde moved uneasily under the scorching light in her
husband’s eyes. It was a new experience to see anything but
tenderness in his face, but she respected him for the look she
resented.
“He had to consult some one, of course. You have given no
attention to things of late.” Her voice was irritatingly even. “Papa
always said you had no head for business.”
“Your father was an honest man, Virginia,” cried her husband,
desperately. “He would have been the last person in the world to
attempt to increase his gains dishonestly.”
“I see nothing dishonest about it,” said Virginia, coldly. “I really
think, Roderick, under all the circumstances, it would have been
more appropriate if you had learned something about money in the
last seven years—besides how to spend it.”
Nothing dishonest!
“Don’t you understand,” demanded Le Garde, in a terrible voice,
“that the ‘commission’ you paid Rogers was blackmail, the price of
his ‘news’ and his silence?”
Mrs. Le Garde shrugged her shoulders.
Roderick rose dumbly. He knew all that he need. The room whirled
round him. How he made his way out of the house he did not know.
Had he served seven years—for this? The fair house of his life, built
up on the insubstantial foundations of a woman’s silence and her
sweet looks, was tumbling about his ears. She whom he had made
his wife, who wore the name he honored though it was his own,
whom he had worshipped as woman never yet was worshipped, had
failed in common honesty, and taunted him with the life he had led
for her sake. She had betrayed him into a shameful position. That
restitution was an easy matter and might be a secret one did not
make the case less hard. He could have defended her had she been
disgraced in the world’s eyes, but how might he defend her from
himself?
It was a raw November night. As he went swiftly on, he felt the
river-mists sweep soft against his face. He wrung his helpless hands.
“Oh, God! It is dishonor! What shall I do? What shall I do?”
No help in the murky sky above him; none in the home whose
lights lay behind; none in the river that rushed along beneath the
bluff—that was the refuge of a coward and a shirk. Had he not
already shirked too much in life?
What must he do? He tried to think collectedly, but in his pain he
could not. There were visions before his eyes. He saw Virginia as
she had seemed to him seven years ago—five years—yesterday—
to-night. Was it true that he had never really seen her till to-night?
Oh, that brave, lost youth of his! His strong, light-hearted youth,
with its poverty, its pride, and its blessed, blessed freedom! If he
could but go back to it, and feel himself his own man once more, with
his life before him to be lived as he had planned it. How was it that
he had become entangled with a soul so alien to his own? And what
did a man do when he reached a point from which he could not go
back, yet loathed to go forward?
He tramped on and on through the drizzling November darkness.
Gradually the tumult in his heart was stilled. He became aware that
the air was cold, that he was splashed with mud and rain, that he
had no hat, and wore only thin evening clothes. He turned at last, his
teeth chattering in his head, and plodded back.
Two things grew clear before his mind—he must settle with
Macomb to-morrow, and he must henceforth assume the control of
John Fenley’s affairs which he had hitherto nominally possessed.
Thank Heaven for the gift of work!
And Virginia?
Who was it who said that for our sins there was all forgiveness, but
our mistakes even infinite mercy could not pardon? Virginia was a
mistake of his; that was all. It was safer to blame himself, not her—
not her. That way lay madness.
Perhaps she, too, had found herself mistaken. Was that the secret
he sometimes fancied he saw stirring behind the curtain of her placid
eyes? If so, God pity them; and God help him to play the part he had
to play.
He had reached his own threshold, and his latch-key faltered in
the door. As he stepped into the wide hall, a curious figure in the
disarray of his fastidious attire, he caught the odor of roses—they
were Maréchal Niels—floating out of the drawing-room. The rooms
were warm and bright and sweet, but their cheer seemed to him
oppressive, and he sickened at the faint perfume of the roses.
His wife came and put the portière aside, standing with one white,
lifted arm outlined against its heavy folds. Virginia always wore
simple evening dress at home for her husband. She had been heard
to say that it was one of the amenities that made domestic life
endurable.
“How long you have been out!” she said, in just her usual sweet,
unhurried voice, ignoring his dishevelled aspect. “I am afraid you are
quite chilled through.”
He looked at her an instant curiously—this exquisite piece of flesh
and blood that was his second self for time and eternity—realizing
that he did not understand her, had never understood her, could
never hope nor desire to do so again. Then he gathered himself
together to make the first speech in the part he had appointed
hereafter to play—that rôle of devoted husband, whose cues he
knew by heart. As he spoke he was shivering slightly, but surely that
was because of the raw outer air.
“What a charming pose!” he said. “Did I ever tell you that
throughout Homer ‘white-armed’ is used as a synonyme for
beautiful?”
RIVALS
“I didn’t presume to suppose that you could care for me yet,” said
Rollinson, humbly.
“I am not at all sure that I cannot,” said the girl, meditatively, “but,
then, neither am I at all sure that I can.” She looked at him with clear,
untroubled eyes as she spoke, eyes in which he read her interest,
her detachment, and her exquisite sincerity. She had not grown
fluttered or self-conscious over his avowal. She was a modern
woman, and she was young. Nothing had yet happened in her life to
disturb her conviction that this was a subject upon which one could
reason as upon other subjects. She was not emotional, and she
suspected that the poets were not unerring guides in matters of the
heart. She liked Rollinson very much, and she was willing to listen to
his arguments.
It seemed to her a little strange that he did not proceed with those
arguments at once, when suddenly she perceived that the adoration
in his eyes was intended as the chief of them, and this discovery was
so disconcerting that she blushed.
“I am twenty years older than you,” murmured Rollinson. As this
was the fact he most wished to forget, he felt it his duty to remind her
of it.
“Nineteen only,” she answered, calmly, “and, besides, I do not see
what that has to do with it. It is not the years but the man one
marries.”
“It is very good of you to think so,” he answered, still humbly, “and
since there is no one else you care for, perhaps in time—”
He left the sentence hanging in the air, as if afraid to finish it, and
neither this modesty nor the yearning tenderness of his accent was
lost upon the girl.
“As you say, there is no one else.”
“But—but there might be,” suggested Rollinson, who was strongly
possessed by the insane delusion of the lover that all men must
needs worship his lady. “Bertha! If you are going to learn to love me,
make haste to be kind. I am horribly unreasonable. I see a rival in
every man you speak to, dance with, smile at. Until my probation is
over I should like to depopulate the world you move in. I want, at
least, to be rejected on my own demerits, not because of the merits
of another man!”
Bertha regarded him attentively, still with that serious, candid air.
“Indeed, I will try,” she murmured, and for the moment he wisely
said no more.
Rollinson had been a thoughtful youth, who early conceived of old
age—which he thought began between forty and forty-five—as one
of the most desirable periods of life.
“Patience! Afterwards,” he had said to himself during the storm
and stress, the confusion and uncertainty of youth—“afterwards,
when I am old, when all this fermentation has ceased, when I know
what I think, what I feel, what I want and can do, how glorious life will
be!”
And in accordance with this conception, as he advanced in years,
he looked confidently for the subsidence of the swelling tide of his
prejudices, passions, partialities, and for the emergence of reason
undefiled as the second Ararat upon which the long-tossed and
buffeted ark of his mind might rest.
To say the least, he was taken aback when, in the midst of those
ripe years, whose fruitage he had hoped to gather in great peace, he
came again upon tempestuous days. In brief, when past forty, it
befell him to love as he had never loved before, and with an unrest
far exceeding that of youth, for he could not fail to see that the
chances were by rights against him.
“Good Lord!” said Rollinson, when he faced his emotional
condition, “for the heart there is no afterwards!”
But, happily, Bertha did not think so ill of his chances for
happiness as did he himself, and he ventured to hope, although he
was terrified by her calmness and her ability to see from all sides the
subject he could only see from one.
Bertha respected his learning and revered his wisdom—which is
learning hitched to life—and envied his experiences, and exulted in
his grasp of people and things, and in his breadth of vision. She
thought such a grip upon life as he possessed could only come with
years. And compared to these things the disadvantages which also
come with years seemed trifling. Obesity, baldness, and a touch of
ancestral gout were the penalties he had to pay for being what he
was. On the whole, the price did not seem too high. She felt quite
sure that she would ultimately accept him, and that they would marry
and live happily ever after.
This impression was still strong in her mind when, some days after
the conversation recorded, she went with her aunt to a little lunch-
party which he gave in his bachelor apartments.
Although he modestly spoke of them as being very simple,
Rollinson’s rooms were really a liberal education. He had been about
the world a great deal and had carried with him fastidious taste and a
purse only moderately filled. As he said once, he had never had so
much money that he could afford to buy trash. The result was very
happy. Pictures, rugs, draperies, brasses, ceramics, all were
satisfactory.
“Your things are so delightfully intelligent!” said Bertha, with a
gratified sigh. He found himself by her side as she was inspecting a
bit of antique silver on a cabinet with obvious approval. “It makes me
feel as I have never felt before, what a wonderful thing is taste!”
He smiled. “I am more than repaid if they have pleased you,” he
said. “Will you step this way an instant? I want to show you the thing
I am vain enough to value most of all.”
In the corner which he indicated, hung a picture she had not
noticed, the portrait of a young man about twenty-five. The girl stared
at it with fascinated eyes. “You! Can it be you?” she questioned, with
an accent that was almost a reproach. Ah, how splendid he was, the
painted youth in his hunter’s costume who stood there fixed forever
in all the beautiful insolence of his young manhood! What a mass of
dark hair tossed back from his fine forehead, and what soldierly
erectness in his bearing! How the eyes flashed—those eyes that
only twinkled now! He was radiant, courageous, strong. What a hold
he had on life—one read it in the lines of his mouth, in his eyes, his
brow. What zest, what eagerness of spirit! He was more than all that
she most admired in her lover, and he was young—young!
The girl gave a strange look at Rollinson and then turned back to
the picture again. All fulfilment is pitiful compared with its prophecy,
and in that moment she realized this.
“It was painted by my friend Van Anden, who died too early to
achieve the fame he should have had,” said Rollinson. “All that
toggery I am wearing, which paints so effectively, was part of my
outfit when I went to Africa with my cousin.”
“It is very fine,” said Bertha, with constraint, and then, with an
unmistakably final movement, she turned away from it. Rollinson felt
a sudden, wretched pang. If she cared at all for him, would not she
also exult in this fair presentment of his young years?
After the luncheon had been served and before his guests had
moved to go, he saw with a hopeful thrill that she had gone back to
the picture and was standing before it again, intent and questioning.
He went up to her.
“Bertha! Dearest!” he said, beneath his breath. “After all, you like
it, then?”
She turned upon him sharply. “It is wonderful—wonderful! But you
should not have shown it to me! I do not understand. I—I thought I
could have married you. Now I know that I never can. I—I never
dreamed there was youth like that in the world. Oh, why did you let
me find it out?”
Rollinson stood dumfounded.
“But it is I,” he found voice to plead at last. “Bertha, have the
added years of worthy life made me less deserving of your love? Am
I to be punished for becoming what he only promised to be?”
The girl passed her hand over her eyes in a bewildered way.
“It seems to me that one can love promise better than
achievement,” she said, faintly. “To care for what is not, is, I fancy,
the very essence of love.”
“I love you as he never could have done,” urged Rollinson. “As he
never dreamed of caring for any one. His loves were superficial and
selfish, Bertha. I have gained much, and I have lost nothing that—
that is essential.”
“You have lost comprehension—he would have understood what I
mean,” answered the girl, quickly.
“But—Bertha! This is unreasonable. How can you expect me to
comprehend?”
“I have been too reasonable!” she cried, with sudden passion.
“That is my discovery. Love is not reasonable, youth is not—and they
belong together. Oh, don’t, don’t make me say any more!”
For an instant there was a heavy silence between them; then
Rollinson found voice to say:
“It shall be as you please. Your aunt seems to be looking for you.
Shall we go over to her?”
When his guests were gone at last, Rollinson came back to the
picture. He took it down and placed it upon a chair where the light fell
full upon it. Truly, he did not look like that to-day.
Although it was himself, he hated it, for it had cost him something
dearer than the young strength which it portrayed. Of all the irrational
humiliations of the long, wayward years of life this seemed to him the
most hideous.
He took his knife from his pocket, opened it and put the point
against the canvas. It would be easy to satisfy the brute anger in his
soul by two sharp cross-cuts which should effectually destroy that
remote, insolent beauty which had once been his own and now was
his no longer.
He hesitated a moment, then dropped the knife and shook his
head. He could not possibly do such a melodramatic, tawdry thing as
that.
He knew that the day might yet come when he should not
remember the bitterness of this hour; he might even grow to be glad
again that he had once walked the earth in the likeness of this
picture, but just now—just now he must forget it for awhile.
With one short sigh, Rollinson lifted the portrait of his rival and set
it down, the face against the wall.
AT THE END OF THE WORLD
“And so, as kinsmen met a night,

We talked between the rooms,
Until the moss had reached our lips,
And covered up our names.”
She was sitting quietly in the sleeper, writing a letter to a friend.

She had got as far as “I feel it my duty to tell you,” when the pencil
flew out of her fingers. She had an instantaneous impression,
grotesque in its horror, that all the natural laws were being unsettled
with a terrible, grinding noise; for the pencil was falling toward the
ceiling instead of the floor, and the man in front of her was following
it, and even she herself. Then something struck her head and she
lost consciousness.
When she came to herself she was lying on a cot in one corner of
a large, unfamiliar room. As her gaze wandered slowly from object to
object on the whitewashed walls, she concluded, from the
combination of railway maps, time-cards, dusty windows filled with
geraniums in pots, and a large, rusty Bible chained to a wall-pocket,
that she was in a country railroad station; but when she turned her
head she saw that it also resembled a hospital. She felt bruised and
sore, but was not in much pain, and only an indefinable sensation of
great weakness warned her not to move.
Presently some one noticed that her eyes were open and, drawing
near, asked her some questions. She answered them with ease, and
then in her turn asked a few. The man, obviously a physician,
answered briefly but definitely. Then he drew a note-book from his
pocket, took down some addresses that she gave him, and moved
away softly in the direction of the telegraph window. She lay, looking
after him incredulously. So this was death! She had at farthest two
more hours on earth. It was part of her creed that one may permit
one’s self to be surprised but never startled. She was not startled
now, but, decidedly, she was sorry. Her best work was yet undone,
and she had not meant to leave earth while there still remained so
much to do.
The sounds and sights of the hastily improvised hospital were
unpleasant to her, and she turned her head away from them. There
was one cot between her and the corner. She recognized the profile
of that bandaged head as belonging to the man who had sat across
the aisle in the sleeper. She had jotted down a description of him in
her note-book, thinking she might use it some day. It ran:
“Sallow skin, soft, brown hair, fine eyes, but an iron mouth with a
devil-may-care expression. He has the get-up of a man who is too
busy being prosperous to take time to be comfortable. His face, a
singular combination of sensitiveness and stolidity, the latter leading.
Neither hard enough for this world nor tender enough for the next. An
Achilles with a dozen vulnerable spots, he sheds two drops of his
own blood for every one he draws in his battles; so, whether he wins
or not, they are always losing fields for him.”
She lay, looking at his profile, thinking that never, so long as she
lived, could she see the other side of that anguished countenance,
and the thought irritated her. This, she reflected, was an instance of
the strength of the ruling passion. She had always been thirstily
curious about life, even to its least details. Now the opportunities for
quenching that thirst were at an end. There was no more for her in
this world of that friction of spirit upon spirit which she loved. She
was dying in a corner. Between herself and the immensity of eternity
hung only that one white face.
Suddenly a thought came into her mind. Why should she not talk
to him—while she was waiting?
“Are you badly hurt?” she asked, softly.
He groaned. “I am a dead man.”
“They tell me I am dying, too,” she said. “Why have they put us
here in this corner, away from the others?”
“Because neither of us is in great pain, and we are both hopeless
cases. They have no time to waste on us.”
“It is very strange to think that this is really the last of it. Are you
prepared to die?”
“Prepared? What is prepared?” he answered. “One is never ready
to stop living. And there were a great many things I wanted to do
yet.”
“Were any of them important?”
An ironic smile twisted the corner of his lips. “Now that you
mention it—no. I wanted to make a good deal more money. I was
going to turn over two or three pieces of real estate next week that I
expected a profit upon. I meant to build a finer house for my wife—a
big, new one, with all the modern wrinkles of architecture and
furnishing. Then, if I had known she was going to have charge of
things so soon, I should have altered one or two investments”——
His pain grew sharper and he groaned. When he was still she
spoke again.
“If I had met you yesterday I should have said that your interests in
life were very much less fine and spiritual than my own. I wrote
things that people praised. They said I was clever, ingenious, witty;
but they never said I was an artist. I meant to make them say it. I
was going to write a novel next winter that should show”—She
stopped, but presently went on, musingly: “It is very odd, but
somehow it doesn’t seem as important as it did this morning. Do you
care that your house will never be built?”
“No.”
“And I don’t care about my novel. I called my interest in life art,
and you called yours business; but neither of them seems to count
any more. The question is, What does count?”
“Close your eyes and lie still for five minutes, and note what you
find yourself unable to avoid thinking of. That will show you what
counts.”
“You have been trying it?”
He made a motion of assent.
“Well,” he asked, after a silence on her part that seemed long,
“does it work?”
“Yes,” she said, in a tense way; “it works too well. What did you
see?”
Again the ironic smile twisted the visible corner of his mouth.
“Shall we exchange confidences—last confessions, and all that? I’d
just as soon. Reticence isn’t worth much now. Only—you begin.”
“I saw,” she said, slowly, “my husband’s eyes. I had forgotten how
they looked when he found that I really meant to insist on a
separation. He could not bear it, for he adored the ground I walked
on. It was five years ago. I had no presentable reason for leaving
him. He was so horribly good-natured that it used to irritate me. And I
didn’t care for the domestic life. It interfered with my work, although
he had promised that it should not. I wanted to be free again. He let
me have the child. He was very good about the whole business—
painfully good, in fact. But it did hurt him cruelly. I have been very
much happier since, but I don’t suppose he has.”
“Did he have brown eyes—the big, faithful, dog-like kind?” asked
the man.
“How did you know?”
“That good sort often do. The girl I jilted did. We had been
engaged almost from our cradles. There was an accident with
horses, and she got hurt. She limped a little afterward, and there
were scars on her face and neck—not very bad scars, but still they
were there. She had been a little beauty before that; but she never at
any time thought much about her looks, and it hadn’t occurred to her
that I minded. But I did mind. I fretted over it until I fancied that I
didn’t love her, after all; but I did. One day I told her so. You know
how she looked at me. She asked if the accident made any
difference, and I hadn’t the skill to lie about it so that she believed
me. She rose at once, as if to put an end to our interview. All she
said was, ‘I thought you knew better what love was.’ I can hear how
her voice sounded. She was badly cut up; lost her health and all that.
And I never could pretend I wasn’t to blame. The girl I married later
was faultlessly pretty, but there was nothing in the world to her.”
“We seem to be a nice sort, don’t we?” said the woman,
reflectively.
“We are no worse than others. Unselfishness is out of fashion.
Everybody takes what he wants nowadays.”
“My husband didn’t.”
“I respect your husband. But you did it. We did the same sort of
thing, you and I; only I think you are the worse of the two. It is natural
for a man to want a wife who isn’t disfigured.”
“It is natural for a clever woman to want to live unfettered.”
“Perhaps. But I erred through the worser part of my nature, and
you through the better. My revolt against unselfishness was physical,
and yours intellectual. Therefore you fell farther than I, by as much
as the mind is better than the body; don’t you see?”
“That is speciously put, but I doubt its truth.”
Both were silent for a space.
“I have it!” she breathed suddenly, and her voice was stronger; for
even in the clutches of death a new insight into the meaning of
things had power to stimulate her whole being. “It is this way. Our
error was the same. We both betrayed their trust in us. We grieved
love. And the reason that we remember now is that love and God are
one, and this is the judgment. That is why we see their eyes
rebuking us. It comes to us, now that we die. That is all life is for—to
learn not to grieve love. Why did I never know it before? Oh, if I had
put that in my books!”
“If you had put it in your life it would have been better,” interrupted
the man; but she went on, unheeding:
“That must be what they meant when they said my work lacked
conviction. It is the heart that takes sides. One man said I was too
clever to be interesting. I never understood what he meant before,
but I see now. It was that I had mind enough but too little heart. I
wanted to become as one of the gods by knowing, and the appointed
path is by loving. To be human and to love is to be divine.”
“Oh, wise conclusion!” mocked the man. “What does it profit you to
know it—now?”
She was silent, spent with the effort of her eager speech. The
maps on the opposite wall whirled before her eyes. She felt herself
slipping—slipping. Yet, though she found no words to tell him why,
there came to her a sudden, sweet assurance that it profited her
much, even at this last hour, to know the thing she had just spoken.
It was a long time before she found strength to ask: “Shall you be
here after I am gone?”
“Why?”
“I gave them my husband’s name. I knew he would be glad to
come. He lives a hundred miles from here, and it will only take him
four hours at the longest. I shall not last that long. If you would tell
him”—
“Tell him what?”
“Tell him,” said the woman, slowly, “that I saw; that I am sorry I
grieved love and him; that I wish I had been wiser about what life
meant; that love is always best.”
“The fact is,” said the man, reluctantly, “I did not mean to stay. I
dabbled in medicine a little once, and I know that I can last this way
a day or two. But I am in pain now, and it will grow worse. What is
the use of staying? They tied an artery for me; it might easily get
untied, you know.”
“Aren’t you going to wait until your wife comes?” she asked,
wonderingly.
“Better not,” answered the man, briefly. “It would hurt her less this
way, and me too. Scenes worry me, and her nerves are delicate.”
“What farces such marriages as yours are!”
“Better a farce than a tragedy. My wife has been happier than your
husband. She has been very comfortable, and she will continue to
be so, for my estate is reasonably large.”
“Then Arthur will never know that I am sorry, and I want him to.
Oh, God! I want him to.”
The man lay, frowning sharply at the ceiling. The ineffectual
anguish of her cry had touched him, but his pain was growing worse.
At last he spoke.
“Look here. If I will stay and deliver that message for you, will you
do something for me?”
“I? What can I do for any one?”
“You are a woman, though not, it seems, a very loving one. You
can tell me if there is any forgiveness for the hurt I gave that girl, and
if there is, absolve me in love’s name! I cannot bear her eyes.”
“Love forgives everything,” she answered, simply. “Wait until you
see Arthur’s face when you tell him I was sorry. That will show you.”
“Say it!” murmured the man, peremptorily. “Let me hear the words,
as she might say them.”
She turned upon her side to smile at him. Her voice had grown so
faint that it seemed but a disembodied, yearning tenderness that
spoke.
“In love’s name, then, and hers, absolvo te”—And the thread of
sound dropped into a silence that was to remain unbroken.
The man lay still, clenching his hands and unclenching them. The
thrusts of pain had grown very sharp, but he grimly set his teeth. He
might ask for morphine; but if he took it “Arthur” might come and go
while he lay in stupor, and the message remain forever undelivered.
He looked at the clock on the opposite wall. Perhaps he had still
three hours to wait. What should he do? That last dart was keenest
of them all. What did people do in torture, people who had made
promises that they must stay to keep? Surely there was something.
Ah, that was it. Of course. They prayed. Then why not he, as well?
His lips moved feverishly.
“Christ, thou who suffered for love’s sake, give me—give me the
pluck to hold out three hours more.”

Neurovascular Surgery Surgical Approaches For Neurovascular Diseases Julius July Download PDF

Uploaded by

Copyright:

Available Formats

Neurovascular Surgery Surgical Approaches For Neurovascular Diseases Julius July Download PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Neurovascular Surgery Surgical Approaches For Neurovascular Diseases Julius July Download PDF

Uploaded by

Copyright:

Available Formats

Full download test bank at ebook textbookfull.

Neurovascular Surgery Surgical

CLICK LINK TO DOWLOAD

New Horizons in Neurovascular Coupling: A Bridge

Atlas of Surgical Approaches for Soft Tissue and

Dr Pestana s Surgery Notes Top 180 Vignettes for the

Drug Delivery Challenges and Novel Therapeutic

Success in Academic Surgery Developing a Career in

Emergency General Surgery, An Issue of Surgical

Cell Biology and Translational Medicine Volume 2

Fundamentals of Orthognathic Surgery and Non Surgical

This book is an open access publication.

Library of Congress Control Number: 2018956495

© The Editor(s) (if applicable) and The Author(s) 2019

Tangerang, Indonesia Julius July

Part I Surgical Approaches

1 Pterional Approach������������������������������������������������������������������������ 3

Part II Surgery for Specific Location of Vascular Lesion

11 Surgery of Posterior Communicating Artery Aneurysm ���������� 87

25 Intracranial Dural Arteriovenous Fistula:

Part III The Miscellaneous Chapter

26 Moyamoya Disease, Basic Concepts of Diagnostics,

Julius July completed his fellowship in neurovascular surgery at the

Jafri Malin Abdullah, MD Department of Neurosciences, Centre for

Harsan, MD, PhD Department of Neurosurgery, Faculty of Medicine

Naoya Kuwayama, MD, PhD Division of Neuroendovascular Therapy,

Bienvenido Ros, MD Department of Neurosurgery, Carlos Haya University

Petra Wahjoepramono, MD Department of Neurosurgery, Medical Faculty

1.1 Introduction 1.2 Steps of the Approach

© The Author(s) 2019 3

nicates directly cistern around the carotid. The

1.2.6 Splitting Sylvian Fissure

Sylvian fissure can be divided into superficial

1.4 Limitations of the Approach

2.1 Basic Consept 2.2 Preoperative Planning

A. Al Fauzi (*) · N. S. Suroto · A. H. Bajamal

© The Author(s) 2019 11

2.3 Step of the Approach anesthetized, the patient head is positioned in

flap is reflected basally and fixed downward with

2.3.4 Intradural Dissection

After opening the dura, the first-step maneuver

2.3.5  losure and Bone Flap

1. Temporary or permanent supraorbital hypes-

“And so, as kinsmen met a night,

She was sitting quietly in the sleeper, writing a letter to a friend.

You might also like

Tangerang, Indonesia Julius July

Part I Surgical Approaches

1 Pterional Approach�� 3

Part II Surgery for Specific Location of Vascular Lesion

11 Surgery of Posterior Communicating Artery Aneurysm �� 87

25 Intracranial Dural Arteriovenous Fistula:

Part III The Miscellaneous Chapter

26 Moyamoya Disease, Basic Concepts of Diagnostics,

1.1 Introduction 1.2 Steps of the Approach

1.2.6 Splitting Sylvian Fissure

1.4 Limitations of the Approach

2.1 Basic Consept 2.2 Preoperative Planning

2.3 Step of the Approach anesthetized, the patient head is positioned in

2.3.4 Intradural Dissection

2.3.5 losure and Bone Flap