Muslin gauze in intracranial vascular surgery

Technical note

Full access

✓ The author comments on three ways in which he has found muslin gauze an aid to clotting in intracranial vascular surgery.

Abstract

✓ The author comments on three ways in which he has found muslin gauze an aid to clotting in intracranial vascular surgery.

In 1958, Gillingham first described the use of muslin to wrap intracranial aneurysms,1 and in the early 1960's the writer introduced this technique to the Neurological Institute of New York.5 “Aneurysms may be snugly and completely wrapped with hammered strips of muscle, fine-meshed gauze, or Gelfoam… muscle wrapping does not always succeed in preventing recurrent hemorrhage or expansion of the aneurysm and Gelfoam is even less reliable in these respects.… A (gauze) wrapping procedure may be the treatment of choice for aneurysms that do not lend themselves to clipping or ligating, either because of a broad base or brittle arteriosclerotic plaques, or because of their location at a bifurcation or trifurcation.”5

My results3,5 and those recently reported by Mount and Antunes,2 testify to the effectiveness of gauze wrapping for certain aneurysms. Renewed interest in the use of muslin gauze in vascular surgery has prompted this note on two other ways in which muslin can be used to advantage: to seal a leak from an injured cerebral artery, and to occlude exceptionally large venous channels of the tentorium.

Sealing a Cerebral Arterial Leak

In 1970, this author developed another use of muslin gauze in intracranial surgery, reported in 1972 as follows: “The application of tiny squares of muslin, fine linen, or gauze, as advocated by Gillingham, is also an effective and simple method for stopping bleeding from a tear in an intracranial artery or aneurysm that cannot be safely occluded. One simply applies three or four squares of muslin, each about 4×4 mm, in layers over the bleeding point and then places cottonoid over them, held gently but firmly in place with a small caliber suction tip for 20 minutes or more.”3

I have used this technique in six cases, with complete neurological recovery in all but one. In three cases, after I clipped the neck of an aneurysm of an internal carotid artery, the artery developed a leak because the wall was friable as a result of arteriosclerotic softening. In two other cases, each with an aneurysm of the anterior communicating artery, an anterior cerebral artery developed a small tear when a tiny branch of the artery was inadvertently avulsed. One of these patients recovered fully, but the other was left with moderate intellectual deficit. In the sixth case, during surgery for an aneurysm of the dominant middle cerebral artery, a small aperture was created in the artery from avulsion of one of its tiny branches. The leak was successfully stopped by muslin and the patient staged a perfect recovery.

A word of caution should be given. Blood usually leaks through the gauze and overlying cottonoid which have been applied to the vessel for several minutes, depending on the size of the artery and the width of the aperture. The sight of this continued oozing may tempt the surgeon to press down heavily upon the cottonoid with his suction tip, but he should resist this temptation. After a short interval, with no pressure and with just continuous gentle suction, the bleeding will stop as clotting occurs within the meshes of the gauze. If one were to press heavily upon the artery, already compromised by local trauma and vasospasm, one might so narrow its lumen that it could become thrombosed. I have no reason to believe that thrombosis has occurred in any vessel so treated, but I am not certain of this because postoperative arteriography was not performed in any of the six cases just cited.

Occlusion of Large Venous Channels

Muslin is also helpful in the occlusion of exceptionally large venous channels in or near the center of one leaf of the tentorium. My experience with this has included three cases: in one patient these channels were opened during removal of a large tentorial meningioma, in another for the removal of an overlying temporal lobe arteriovenous malformation, and in the third for invasive cylindroma of the tentorium. In these three cases, when efforts to cease the flow of blood by ligatures, clips, and large muscle stamps had failed, the gaping channels were quickly and simply occluded by stuffing them with just enough muslin to stop the bleeding. All three patients recovered.

Again a word of caution is in order. A thread should be passed through the muslin before inserting the muslin in the lumen of the venous channel. The suture material enables the surgeon to control the muslin and also to anchor it securely to the tentorium after it has been placed in the venous channel. Wek clips have also been used to anchor the muslin to the tentorium.

Comment

In summary, there are three ways in which muslin gauze may be found useful in intracranial surgery: for wrapping certain aneurysms; for sealing a leaking or torn cerebral artery; and for occluding exceptionally large venous channels of the tentorium.4

References

  • 1.

    Gillingham FJ: The management of ruptured intracranial aneurysm. Hunterian Lecture. Ann R Coll Surg Eng 23:891171958Gillingham FJ: The management of ruptured intracranial aneurysm. Hunterian Lecture. Ann R Coll Surg Eng 23:

  • 2.

    Mount LAAntunes JL: Result of treatment of intracranial aneurysms by wrapping and coating. J Neurosurg 42:1891931975J Neurosurg 42:

  • 3.

    Pool JL: Bifrontal craniotomy for anterior communicating artery aneurysms. J Neurosurg 36:2122201972Pool JL: Bifrontal craniotomy for anterior communicating artery aneurysms. J Neurosurg 36:

  • 4.

    Pool JL: LakevilleConn, Pocket Knife Press1975Pool JL: The Neurological Institute of New York: 1909–1974. With personal anecdotes

  • 5.

    Pool JLPotts DG: Aneurysms and Arteriovenous Malformations of the Brain.New YorkHarper & Row1965Aneurysms and Arteriovenous Malformations of the Brain

Article Information

Address reprint requests to: J. Lawrence Pool, M.D., Box 31, West Cornwall, Connecticut 06796.

© AANS, except where prohibited by US copyright law.

Headings

References

1.

Gillingham FJ: The management of ruptured intracranial aneurysm. Hunterian Lecture. Ann R Coll Surg Eng 23:891171958Gillingham FJ: The management of ruptured intracranial aneurysm. Hunterian Lecture. Ann R Coll Surg Eng 23:

2.

Mount LAAntunes JL: Result of treatment of intracranial aneurysms by wrapping and coating. J Neurosurg 42:1891931975J Neurosurg 42:

3.

Pool JL: Bifrontal craniotomy for anterior communicating artery aneurysms. J Neurosurg 36:2122201972Pool JL: Bifrontal craniotomy for anterior communicating artery aneurysms. J Neurosurg 36:

4.

Pool JL: LakevilleConn, Pocket Knife Press1975Pool JL: The Neurological Institute of New York: 1909–1974. With personal anecdotes

5.

Pool JLPotts DG: Aneurysms and Arteriovenous Malformations of the Brain.New YorkHarper & Row1965Aneurysms and Arteriovenous Malformations of the Brain

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 5 5 5
Full Text Views 73 73 39
PDF Downloads 84 84 51
EPUB Downloads 0 0 0

PubMed

Google Scholar