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Drexler R, Sauvigny T, Pantel TF, Ricklefs FL, Catapano JS, Wanebo JE, Lawton MT, Sanchin A, Hecht N, Vajkoczy P, Raygor K, Tonetti D, Abla A, El Naamani K, Tjoumakaris SI, Jabbour P, Jankowitz BT, Salem MM, Burkhardt JK, Wagner A, Wostrack M, Gempt J, Meyer B, Gaub M, Mascitelli JR, Dodier P, Bavinzski G, Roessler K, Stroh N, Gmeiner M, Gruber A, Figueiredo EG, da Silva Coelho ACS, Bervitskiy AV, Anisimov ED, Rzaev JA, Krenzlin H, Keric N, Ringel F, Park D, Kim MC, Marcati E, Cenzato M, Westphal M, Dührsen L. Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases. Neurosurgery 2024; 94:369-378. [PMID: 37732745 PMCID: PMC10766286 DOI: 10.1227/neu.0000000000002689] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias F. Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L. Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joshua S. Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - John E. Wanebo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Aminaa Sanchin
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kunal Raygor
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daniel Tonetti
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Adib Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I. Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian T. Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Mohamed M. Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Arthur Wagner
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich (TUM), Munich, Germany
| | - Michael Gaub
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Justin R. Mascitelli
- Department of Neurosurgery, University of Texas Health and Science Center at San Antonio, San Antonio, Texas, USA
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Roessler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Nico Stroh
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Eberval G. Figueiredo
- Division of Neurological Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Harald Krenzlin
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Hospital Mainz, Mainz, Germany
| | - Dougho Park
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Mun-Chul Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea
| | - Eleonora Marcati
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Cenzato
- Department of Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Ansari A, Kalyan S, Sae-Ngow T, Yamada Y, Tanaka R, Kawase T, Kato Y. Review of Avoidance of Complications in Cerebral Aneurysm Surgery: The Fujita Experience. Asian J Neurosurg 2019; 14:686-692. [PMID: 31497085 PMCID: PMC6703062 DOI: 10.4103/ajns.ajns_131_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Avoidance of complications during cerebral aneurysm surgery marks the future outcome in the patient. Various modalities such as adequate opening of the Sylvian fissure, motor-evoked potential, endoscope-assisted microsurgery, indocyanine green dye, and dual image video angiography are available to reduce these complications during surgery, either by prevention of injury to the small perforators or the parent artery. We present our experience at the Fujita Health University Banbuntane Hospital, Japan, of the cerebral aneurysm surgery along with the use of these modalities in our patients from September 2014 to December 2016 along with a brief review of the various techniques for avoidance of complications.
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Affiliation(s)
- Ahmed Ansari
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Sai Kalyan
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Treepob Sae-Ngow
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Riki Tanaka
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Fujita Health University, Nagoya, Japan
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Bae HJ, Choi JH, Kim BS, Lee KS, Shin YS. Predictors of Atherosclerotic Change in Unruptured Intracranial Aneurysms and Parent Arteries During Clipping. World Neurosurg 2019; 130:e338-e343. [PMID: 31228701 DOI: 10.1016/j.wneu.2019.06.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To identify predictors of atherosclerotic change in aneurysms and parent arteries, and to retrospectively analyze outcomes from clipped aneurysms that showed atherosclerotic changes. METHODS Between May 2017 and April 2018, we collected a total of 151 clipping cases and reviewed records of operation videos to classify atherosclerosis by location (dome, neck of aneurysm, or parent artery). To identify predictors of atherosclerotic change in aneurysms, we analyzed baseline demographic characteristics, preoperative images, and Framingham Risk Scores (FRS). We also analyzed incomplete clipping cases according to atherosclerosis presence and location. RESULT This study cohort included 110 women (mean age, 59.3 ± 7.1 years) and 41 men (mean age, 55.9 ± 9.6 years). Atherosclerotic change was seen in 77 cases. FRS, diabetes mellitus, and aneurysm size were identified as independent risk factors for atherosclerotic change in multivariate logistic regression analysis. There were 11 incomplete clipping cases (7.2%). Among the 30 cases with atherosclerotic change in the neck were 10 cases of incomplete clipping (P < 0.001). CONCLUSIONS FRS, diabetes mellitus, and aneurysm size as predictors of atherosclerosis in patients undergoing aneurysm surgery can help guide surgical decisions and performance.
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Affiliation(s)
- Hong-Ju Bae
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Bum Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Kwan-Sung Lee
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea.
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Chung J, Park W, Hong SH, Park JC, Ahn JS, Kwun BD, Lee SA, Kim SH, Jeon JY. Intraoperative use of transcranial motor/sensory evoked potential monitoring in the clipping of intracranial aneurysms: evaluation of false-positive and false-negative cases. J Neurosurg 2019; 130:936-948. [PMID: 29570008 DOI: 10.3171/2017.8.jns17791] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/21/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Somatosensory and motor evoked potentials (SEPs and MEPs) are often used to prevent ischemic complications during aneurysm surgeries. However, surgeons often encounter cases with suspicious false-positive and false-negative results from intraoperative evoked potential (EP) monitoring, but the incidence and possible causes for these results are not well established. The aim of this study was to investigate the efficacy and reliability of EP monitoring in the microsurgical treatment of intracranial aneurysms by evaluating false-positive and false-negative cases. METHODS From January 2012 to April 2016, 1514 patients underwent surgery for unruptured intracranial aneurysms (UIAs) with EP monitoring at the authors' institution. An EP amplitude decrease of 50% or greater compared with the baseline amplitude was defined as a significant EP change. Correlations between immediate postoperative motor weakness and EP monitoring results were retrospectively reviewed. The authors calculated the sensitivity, specificity, and positive and negative predictive values of intraoperative MEP monitoring, as well as the incidence of false-positive and false-negative results. RESULTS Eighteen (1.19%) of the 1514 patients had a symptomatic infarction, and 4 (0.26%) had a symptomatic hemorrhage. A total of 15 patients showed motor weakness, with the weakness detected on the immediate postoperative motor function test in 10 of these cases. Fifteen false-positive cases (0.99%) and 8 false-negative cases (0.53%) were reported. Therefore, MEP during UIA surgery resulted in a sensitivity of 0.10, specificity of 0.94, positive predictive value of 0.01, and negative predictive value of 0.99. CONCLUSIONS Intraoperative EP monitoring has high specificity and negative predictive value. Both false-positive and false-negative findings were present. However, it is likely that a more meticulously designed protocol will make EP monitoring a better surrogate indicator of possible ischemic neurological deficits.
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Affiliation(s)
| | | | | | | | | | | | | | - Sung-Hoon Kim
- 3Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Algra AM, Lindgren A, Vergouwen MDI, Greving JP, van der Schaaf IC, van Doormaal TPC, Rinkel GJE. Procedural Clinical Complications, Case-Fatality Risks, and Risk Factors in Endovascular and Neurosurgical Treatment of Unruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:282-293. [PMID: 30592482 PMCID: PMC6439725 DOI: 10.1001/jamaneurol.2018.4165] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/02/2018] [Indexed: 01/16/2023]
Abstract
Importance The risk of procedural clinical complications and the case-fatality rate (CFR) from preventive treatment of unruptured intracranial aneurysms varies between studies and may depend on treatment modality and risk factors. Objective To assess current procedural clinical 30-day complications and the CFR from endovascular treatment (EVT) and neurosurgical treatment (NST) of unruptured intracranial aneurysms and risk factors of clinical complications. Data Sources We searched PubMed, Excerpta Medica Database, and the Cochrane Database for studies published between January 1, 2011, and January 1, 2017. Study Selection Studies reporting on clinical complications, the CFR, and risk factors, including 50 patients or more undergoing EVT or NST for saccular unruptured intracranial aneurysms after January 1, 2000, were eligible. Data Extraction and Synthesis Per treatment modality, we analyzed clinical complication risk and the CFR with mixed-effects logistic regression models for dichotomous data. For studies reporting data on complication risk factors, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% CIs and pooled risk estimates with weighted random-effects models. Main Outcomes and Measures Clinical complications within 30 days and the CFR. Results We included 114 studies (106 433 patients with 108 263 aneurysms). For EVT (74 studies), the pooled clinical complication risk was 4.96% (95% CI, 4.00%-6.12%), and the CFR was 0.30% (95% CI, 0.20%-0.40%). Factors associated with complications from EVT were female sex (pooled OR, 1.06 [95% CI, 1.01-1.11]), diabetes (OR, 1.81 [95% CI, 1.05-3.13]), hyperlipidemia (OR, 1.76 [95% CI, 1.3-2.37]), cardiac comorbidity (OR, 2.27 [95% CI, 1.53-3.37]), wide aneurysm neck (>4 mm or dome-to-neck ratio >1.5; OR, 1.71 [95% CI, 1.38-2.11]), posterior circulation aneurysm (OR, 1.42 [95% CI, 1.15-1.74]), stent-assisted coiling (OR, 1.82 [95% CI, 1.16-2.85]), and stenting (OR, 3.43 [95% CI, 1.45-8.09]). For NST (54 studies), the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the CFR was 0.10% (95% CI, 0.00%-0.20%). Factors associated with complications from NST were age (OR per year increase, 1.02 [95% CI, 1.01-1.02]), female sex (OR, 0.43 [95% CI, 0.32-0.85]), coagulopathy (OR, 2.14 [95% CI, 1.13-4.06]), use of anticoagulation (OR, 6.36 [95% CI, 2.55-15.85]), smoking (OR, 1.95 [95% CI, 1.36-2.79]), hypertension (OR, 1.45 [95% CI, 1.03-2.03]), diabetes (OR, 2.38 [95% CI, 1.54-3.67]), congestive heart failure (OR, 2.71 [95% CI, 1.57-4.69]), posterior aneurysm location (OR, 7.25 [95% CI, 3.70-14.20]), and aneurysm calcification (OR, 2.89 [95% CI, 1.35-6.18]). Conclusions and Relevance This study identifies risk factors for procedural complications. Large data sets with individual patient data are needed to develop and validate prediction scores for absolute complication risks and CFRs from EVT and NST modalities.
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Affiliation(s)
- Annemijn M. Algra
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Antti Lindgren
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Department of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mervyn D. I. Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jacoba P. Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene C. van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Tristan P. C. van Doormaal
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gabriel J. E. Rinkel
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Hemodynamic findings associated with intraoperative appearances of intracranial aneurysms. Neurosurg Rev 2018; 43:203-209. [DOI: 10.1007/s10143-018-1027-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 08/04/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
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Konczalla J, Platz J, Fichtlscherer S, Mutlak H, Strouhal U, Seifert V. Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: results of an interdisciplinary prospective trial. J Neurosurg 2018; 128:1741-1752. [DOI: 10.3171/2016.11.jns161420] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVETo date, treatment of complex unruptured intracranial aneurysms (UIAs) remains challenging. Therefore, advanced techniques are required to achieve an optimal result in treating these patients safely. In this study, the safety and efficacy of rapid ventricular pacing (RVP) to facilitate microsurgical clip reconstruction was investigated prospectively in a joined neurosurgery, anesthesiology, and cardiology study.METHODSPatients with complex UIAs were prospectively enrolled. Both the safety and efficacy of RVP were evaluated by recording cardiovascular events and outcomes of patients as well as the amount of aneurysm occlusion after the surgical clip reconstruction procedure. A questionnaire was used to evaluate aneurysm preparation and clip application under RVP.RESULTSTwenty patients (mean age 51.6 years, range 28–66 years) were included in this study. Electrode positioning was easy in 19 (95%) of 20 patients, and removal of electrodes was easily accomplished in all patients (100%). No complications associated with the placement of the pacing electrodes occurred, such as cardiac perforation or cardiac tamponade. RVP was applied in 16 patients. The mean aneurysm size was 11.1 ± 5.5 mm (range 6–30 mm). RVP proved to be a very helpful tool in aneurysm preparation and clip application in 15 (94%) of 16 patients. RVP was used for a mean duration of 60 ± 25 seconds, a mean heart rate of 173 ± 23 bpm (range 150–210 bpm), and a reduction of mean arterial pressure to 35–55 mm Hg. RVP leads to softening of the aneurysm sac facilitating its mobilization, clip application, and closure of the clip blades. In 2 patients, cardiac events were documented that resolved without permanent sequelae in both. In every patient with successful RVP (n = 14) a total or near-total aneurysm occlusion was documented. In the 1 patient in whom the second RVP failed due to pacemaker electrode dislocation, additional temporary clipping was required to secure the aneurysm, but was not as sufficient as RVP. This led to an incomplete clipping of the aneurysm and finally a remnant on postoperative digital subtraction angiography. A pacemaker lead dislocation occurred in 3 (19%) of 16 patients, but intraoperative repositioning requires less than 20 seconds. Outcome was favorable in all patients according to the modified Rankin Scale.CONCLUSIONSTo the best of the authors’ knowledge this is the first prospective interdisciplinary study of RVP use in patients with UIAs. RVP is an elegant technique that facilitates clip reconstruction in complex UIAs. The safety of the procedure is good. However, because this procedure requires extensive preoperative cardiological workup of the patient and an experienced neurosurgery and neuroanesthesiology team with much cerebrovascular expertise, actually it remains reserved for selected elective cases and highly specialized centers.Clinical trial registration no.: NCT02766972 (clinicaltrials.gov)
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Affiliation(s)
| | | | | | - Haitham Mutlak
- 3Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Ulrich Strouhal
- 3Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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8
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Microsurgical Clipping of Intracranial Aneurysms Assisted by Neurophysiological Monitoring, Microvascular Flow Probe, and ICG-VA: Outcomes and Intraoperative Data on a Multimodal Strategy. World Neurosurg 2018; 113:e336-e344. [DOI: 10.1016/j.wneu.2018.02.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/03/2018] [Accepted: 02/05/2018] [Indexed: 02/08/2023]
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9
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Furukawa K, Ishida F, Tsuji M, Miura Y, Kishimoto T, Shiba M, Tanemura H, Umeda Y, Sano T, Yasuda R, Shimosaka S, Suzuki H. Hemodynamic characteristics of hyperplastic remodeling lesions in cerebral aneurysms. PLoS One 2018; 13:e0191287. [PMID: 29338059 PMCID: PMC5770072 DOI: 10.1371/journal.pone.0191287] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/02/2018] [Indexed: 11/23/2022] Open
Abstract
Background & purpose Hyperplastic remodeling (HR) lesions are sometimes found on cerebral aneurysm walls. Atherosclerosis is the results of HR, which may cause an adverse effect on surgical treatment for cerebral aneurysms. Previous studies have demonstrated that atherosclerotic changes had a correlation with certain hemodynamic characteristics. Therefore, we investigated local hemodynamic characteristics of HR lesions of cerebral aneurysms using computational fluid dynamics (CFD). Methods Twenty-four cerebral aneurysms were investigated using CFD and intraoperative video recordings. HR lesions and red walls were confirmed on the intraoperative images, and the qualification points were determined on the center of the HR lesions and the red walls. The qualification points were set on the virtual operative images for evaluation of wall shear stress (WSS), normalized WSS (NWSS), oscillatory shear index (OSI), relative residence time (RRT), and aneurysm formation indicator (AFI). These hemodynamic parameters at the qualification points were compared between HR lesions and red walls. Results HR lesions had lower NWSS, lower AFI, higher OSI and prolonged RRT compared with red walls. From analysis of the receiver-operating characteristic curve for hemodynamic parameters, OSI was the most optimal hemodynamic parameter to predict HR lesions (area under the curve, 0.745; 95% confidence interval, 0.603–0.887; cutoff value, 0.00917; sensitivity, 0.643; specificity, 0.893; P<0.01). With multivariate logistic regression analyses using stepwise method, NWSS was significantly associated with the HR lesions. Conclusions Although low NWSS was independently associated with HR lesions, OSI is the most valuable hemodynamic parameter to distinguish HR lesions from red walls.
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Affiliation(s)
- Kazuhiro Furukawa
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
- * E-mail:
| | - Fujimaro Ishida
- Department of Neurosurgery, Mie Chuo Medical Center, National Hospital Organization, Tsu, Mie, Japan
| | - Masanori Tsuji
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Yoichi Miura
- Department of Neurosurgery, Suzuka Kaisei Hospital, Suzuka, Mie, Japan
| | - Tomoyuki Kishimoto
- Department of Neurosurgery, Mie Chuo Medical Center, National Hospital Organization, Tsu, Mie, Japan
| | - Masato Shiba
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hiroshi Tanemura
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Yasuyuki Umeda
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Takanori Sano
- Department of Neurosurgery, Ise Red Cross Hospital, Ise, Mie, Japan
| | - Ryuta Yasuda
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Shinichi Shimosaka
- Department of Neurosurgery, Mie Chuo Medical Center, National Hospital Organization, Tsu, Mie, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Asymptomatic Ischemic Risks in Microsurgical Clipping for Unruptured Intracranial Aneurysms in Anterior Circulation. World Neurosurg 2017; 108:418-426. [DOI: 10.1016/j.wneu.2017.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/02/2017] [Accepted: 09/04/2017] [Indexed: 11/23/2022]
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11
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Platz J, Wagner M, Güresir E, You SJ, Konczalla J, de Rochemont RDM, Berkefeld J, Seifert V. Early diffusion-weighted MRI lesions after treatment of unruptured intracranial aneurysms: a prospective study. J Neurosurg 2017; 126:1070-1078. [DOI: 10.3171/2016.2.jns152456] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Diffusion-weighted MRI was used to assess periprocedural lesion load after repair of unruptured intracranial aneurysms (UIA) by microsurgical clipping (MC) and endovascular coiling (EC).
METHODS
Patients with UIA were assigned to undergo MC or EC according to interdisciplinary consensus and underwent diffusion-weighted imaging (DWI) 1 day before and 1 day after aneurysm treatment. Newly detected lesions by DWI after treatment were the primary end point of this prospective study. Lesions detected by DWI were categorized as follows: A) 1–3 DWI spots < 10 mm, B) > 3 DWI spots < 10 mm, C) single DWI lesion > 10 mm, or D) DWI lesion related to surgical access.
RESULTS
Between 2010 and 2014, 99 cases were included. Sixty-two UIA were treated by MC and 37 by EC. There were no significant differences between groups in age, sex, aneurysm size, occurrence of multiple aneurysms in 1 patient, or presence of lesions detected by DWI before treatment. Aneurysms treated by EC were significantly more often located in the posterior circulation (p < 0.001). Diffusion-weighted MRI detected new lesions in 27 (43.5%) and 20 (54.1%) patients after MC and EC, respectively (not significant). The pattern of lesions detected by DWI varied significantly between groups (p < 0.001). Microembolic lesions (A and B) found on DWI were detected more frequently after EC (A, 14 cases; B, 5 cases) than after MC (A, 5 cases), whereas C and D were rare after EC (C, 1 case) and occurred more often after MC (C, 12 cases and D, 10 cases). No procedure-related unfavorable outcomes were detected.
CONCLUSIONS
According to the specific techniques, lesion patterns differ between MC and EC, whereas the frequency of new lesions found on DWI is similar after occlusion of UIA. In general, the lesion load was low in both groups, and lesions were clinically silent.
Clinical trial registration no.: NCT01490463 (clinicaltrials.gov)
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Affiliation(s)
| | - Marlies Wagner
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | | | - Se-Jong You
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | | | | | - Joachim Berkefeld
- 2Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
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Dual-Channel Endoscopic Indocyanine Green Fluorescence Angiography for Clipping of Cerebral Aneurysms. World Neurosurg 2017; 100:316-324. [DOI: 10.1016/j.wneu.2017.01.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/08/2017] [Accepted: 01/10/2017] [Indexed: 11/21/2022]
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13
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Treatment of Large and Giant Middle Cerebral Artery Aneurysms: Risk Factors for Unfavorable Outcomes. World Neurosurg 2017; 102:301-312. [PMID: 28323182 DOI: 10.1016/j.wneu.2017.03.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study aimed to assess the clinical and radiologic outcomes after neurosurgical treatment of large and giant aneurysms of the middle cerebral artery (MCA). In addition, we aimed to identify risk factors for unfavorable outcomes. METHODS This retrospective study included 105 patients with 106 large or giant MCA aneurysms treated with neurosurgical methods, including microsurgery and endovascular treatment, over a 15-year period. RESULTS The mean aneurysm size was 15.3 ± 7.1 mm. Ten (9.4%) were giant aneurysms. The MCA bifurcation was the most common aneurysm site, followed by the MCA trunk and distal MCA. Aneurysm clipping was the most common treatment method, followed by clipping or trapping with bypass surgery and endovascular treatment. However, acute cerebral infarction was the most common complication (16.0%), poor outcomes (modified Rankin Scale score, 3-6) developed in 12.3% of aneurysms after treatment, and 6.6% of treated aneurysms needed retreatment. Multivariate analysis showed that independent risk factors for acute cerebral infarction after treatment were aneurysms located on the MCA trunk and 2 or more underlying diseases. Initial presentation with subarachnoid hemorrhage and complications during treatment were independent risk factors for poor outcomes. In addition, endosaccular coiling was an independent risk factor for retreatment. CONCLUSIONS Neurosurgical management should be considered a priority for large and giant MCA aneurysms because of the high rupture rate and clinical symptoms. However, treatment outcomes remain unsatisfactory. Therefore, tailored management with consideration of risk factors for unfavorable outcomes should be implemented.
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Yamada Y, Kato Y, Nouri M, Ganaha T, Oheda M, Ishihara K, Moriya S, Sadato A, Inamasu J, Hirose Y. Predictive Value of Motor Evoked Potential Monitoring during Surgery of Unruptured Anterior Circulation Cerebral Aneurysms. Asian J Neurosurg 2017; 12:644-647. [PMID: 29114276 PMCID: PMC5652088 DOI: 10.4103/ajns.ajns_135_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective and Background: Surgery of unruptured aneurysms is always a great challenge to neurovascular surgeons because no postoperative neurological deficits should be expected postoperatively as the patients are fully asymptomatic before the surgery. Here, we present our experience with selective motor evoked potential (MEP) monitoring of our patients in a 2-year time window. Patients and Methods: From 2012 to 2014, 27 patients with unruptured intracranial aneurysms were operated in our institute with the help of MEP monitoring. All patients underwent endoscope-assisted microsurgery with pre- and post-clipping indocyanine green angiography. Results: In this period, no mortality was observed, but 18.5% of the patients developed postoperative deficits which showed good recovery in all cases. Overall, MEP showed about 90% accuracy in predicting postoperative deficits. Conclusions: MEP as a part of multimodality monitoring of aneurysm surgeries is a valuable tool to improve the outcome. However, we should know its limitations as its results are not always consistent with the outcome.
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Affiliation(s)
- Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Mohsen Nouri
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Tsukasa Ganaha
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Motoki Oheda
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Kohei Ishihara
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Shigeta Moriya
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Akiyo Sadato
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Joji Inamasu
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
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15
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Aneurysm Clip Compression Technique in the Surgery of Aneurysms with Hard/Calcified Neck. World Neurosurg 2015; 84:688-96. [DOI: 10.1016/j.wneu.2015.04.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 11/24/2022]
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16
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Matsushige T, Akiyama Y, Okazaki T, Shinagawa K, Ichinose N, Awai K, Kurisu K. Vascular Wall Imaging of Unruptured Cerebral Aneurysms with a Hybrid of Opposite-Contrast MR Angiography. AJNR Am J Neuroradiol 2015; 36:1507-11. [PMID: 25929881 DOI: 10.3174/ajnr.a4318] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 01/09/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Inflammation and degeneration of the intracranial saccular aneurysm wall play a major role in aneurysm formation, development and subsequent rupture. The aim of this study was to characterize the walls of unruptured intracranial aneurysms by using a hybrid of opposite-contrast MRA at 3T. MATERIALS AND METHODS Fourteen consecutive patients with 17 unruptured intracranial aneurysms who initially underwent clipping surgery were prospectively evaluated. All aneurysms were scanned preoperatively by using a hybrid of opposite-contrast MRA in 3T high-resolution MR imaging. We classified intraoperative findings of atherosclerotic plaques in the aneurysms into 3 grades: grade A (major plaques), grade B (minor plaques), and grade C (no plaques). The contrast ratio of the high-intensity area was also measured relative to the background low-intensity area inside the carotid artery. RESULTS Findings from preoperative plaque imaging of the aneurysm corresponded to the intraoperative findings in 15 of 16 aneurysms (excluding 1 that was impossible to visualize in its entirety due to anatomic reasons). Overall sensitivity and specificity of the hybrid of opposite-contrast MRA were 88.9% and 100%, respectively. During the operation, 4 aneurysms were classified as grade A; 5, as grade B; and 7, as grade C. The means of the contrast ratio for grades A, B, and C were 0.72 ± 0.03, 0.34 ± 0.30, and -0.02 ± 0.09, respectively. CONCLUSIONS The hybrid of opposite-contrast MRA can detect visible atherosclerotic plaques in the unruptured aneurysm wall, and the contrast ratio in intracranial aneurysms correlated with their presence and extent. A study including a larger series is needed to validate the diagnostic potential of this imaging technique.
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Affiliation(s)
- T Matsushige
- From the Department of Neurosurgery (T.M., T.O., K.S., N.I., K.K.), Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan Department of Neurosurgery (T.M.), University Hospital Essen, Essen, Germany
| | - Y Akiyama
- Department of Diagnostic Radiology (Y.A., K.A.), Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - T Okazaki
- From the Department of Neurosurgery (T.M., T.O., K.S., N.I., K.K.), Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - K Shinagawa
- From the Department of Neurosurgery (T.M., T.O., K.S., N.I., K.K.), Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - N Ichinose
- From the Department of Neurosurgery (T.M., T.O., K.S., N.I., K.K.), Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - K Awai
- Department of Diagnostic Radiology (Y.A., K.A.), Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - K Kurisu
- From the Department of Neurosurgery (T.M., T.O., K.S., N.I., K.K.), Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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17
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Park W, Ahn JS, Lee SH, Park JC, Kwun BD. Results of re-exploration because of compromised distal blood flow after clipping unruptured intracranial aneurysms. Acta Neurochir (Wien) 2015; 157:1015-24; discussion 1024. [PMID: 25845552 DOI: 10.1007/s00701-015-2408-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/18/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND One of the major causes for performing unplanned re-exploration of a craniotomy after microsurgery for unruptured intracranial aneurysms (UIAs) is compromised distal blood flow after clipping. Therefore, it is important to identify the causes of compromised distal blood flow after clipping and the factors that influence the prognosis for re-exploration in order to decrease ischemic complications related to clipping UIAs. METHOD Between January 2007 and December 2013, 1954 patients underwent microsurgery for UIAs. In this cohort, 20 patients (1.0%) required unplanned re-exploration of the craniotomy for several reasons, and 11 patients (0.6%) underwent unplanned re-exploration with clip repositioning or changing of the previous clip because of compromised distal blood flow after clipping. Patient characteristics, aneurysm properties, intraoperative findings, annual incidence and prognosis were analyzed in these 11 patients. RESULTS The annual incidence of re-exploration has gradually decreased since the introduction of several intraoperative monitoring techniques. In total, 3.0% of UIAs in the M1 trunk, 0.8% of UIAs at the origin of the anterior choroidal artery (AchA) and 0.5% of UIAs at the bifurcation of the middle cerebral artery (MCA) required re-exploration. Here, all 11 UIAs had broad necks, and atherosclerosis was identified around 10 UIAs. Six patients with compromised MCA flow demonstrated relatively better outcomes following re-exploration than five patients with a compromised lenticulostriate artery (LSA) or AchA flow. Four patients with delayed ischemic symptoms demonstrated relatively better outcomes than the seven patients who developed ischemic symptoms immediately postoperatively. CONCLUSION Clinicians need to be more careful not to compromise distal blood flow when clipping UIAs at the MCA and AchA origin. Various intraoperative monitoring techniques can help reduce the incidence of compromised distal blood flow after clipping.
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Affiliation(s)
- Wonhyoung Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736 l, South Korea
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Yamada Y, Kato Y, Ishihara K, Ito K, Kaito T, Nouri M, Oheda M, Inamasu J, Hirose Y. Role of endoscopy in multi-modality monitoring during aneurysm surgery: A single center experience with 175 consecutive unruptured aneurysms. Asian J Neurosurg 2015; 10:52. [PMID: 25767585 PMCID: PMC4352638 DOI: 10.4103/1793-5482.151518] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective and Background: Unruptured aneurysm surgery is a challenge to all vascular neurosurgeons as the patient is asymptomatic and no even slight neurological deficits should be expected postoperatively. To this aim, multi-modality checking of the vessels during the surgery is highly recommended to assure of the patency of the parent and perforator arteries next to an aneurysm. In this paper, we present our experience in the last 1.5 years with emphasis on the role of endoscope assisted microsurgery. Methods: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years. All patients underwent endoscope assisted microsurgery with pre- and post-clipping indocyanine green angiography. In selected cases, motor evoked potential monitoring was implemented. Results: No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively. Our illustrative cases show how endoscopy may help the surgeon to visualize hidden vessels behind and medial to an aneurysm. Conclusions: Our results indicated that multi-modality monitoring during unruptured aneurysm surgeries is associated with excellent outcome. Endoscope is able to show blind corners during aneurysm surgery which cannot be routinely observed with microscope and its application in aneurysm surgery assists the surgeon to make certain of complete neck clipping and preservation of perforating arteries around the aneurysm.
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Affiliation(s)
- Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Kohei Ishihara
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Keisuke Ito
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Takafumi Kaito
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Mohsen Nouri
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Motoki Oheda
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Joji Inamasu
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan
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Park CK, Shin HS, Choi SK, Lee SH, Koh JS. Clinical analysis and surgical considerations of atherosclerotic cerebral aneurysms: experience of a single center. J Cerebrovasc Endovasc Neurosurg 2014; 16:247-53. [PMID: 25340027 PMCID: PMC4205251 DOI: 10.7461/jcen.2014.16.3.247] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/29/2014] [Accepted: 09/04/2014] [Indexed: 11/23/2022] Open
Abstract
Objective Atherosclerotic cerebral aneurysms are known to increase occurrence of thromboembolic events and occlusion of perforator vessels intraoperatively due to pathological changes in the vessels themselves. In the current study, we analyzed the points to be considered during surgery for atherosclerotic cerebral aneurysms and the postoperative results. Materials and Methods We retrospectively reviewed the medical records, radiological results, and surgical records, including intraoperative video recordings and photographs, of 262 patients who underwent cerebral aneurysm surgery. We then performed a detailed analysis of aneurysm features, surgical methods, and clinical outcomes. Results Among 278 aneurysms in 262 patients, 73 aneurysms in 67 patients showed atherosclerotic features (atherosclerotic group, AG), and 205 aneurysms in 195 patients showed no evidence of atherosclerosis (non-atherosclerotic group, NAG). In the AG, clipping with multiple permanent clips was performed in 14 aneurysms, and clip slippage was found in four cases. Six AG cases had a remnant neck after clipping, which was significantly more frequent than in the NAG (p < 0.05). Clinical outcomes and surgery-related complications did not differ significantly between the two groups. Conclusion In the surgical repair of aneurysms, the incidence of ischemia, which is irreversible or severe, might be greater in atherosclerotic than in non-atherosclerotic aneurysms. In addition, multiple clips might be applied to atherosclerotic aneurysms for effective obliteration and an aneurysm neck might be left to avoid a region of atheroma.
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Affiliation(s)
- Chang Kyu Park
- Department of Neurosurgery, KyungHee University Hospital, Seoul, Korea
| | - Hee Sup Shin
- Department of Neurosurgery, KyungHee University Hospital at Gangdong, Seoul, Korea
| | - Seok Keun Choi
- Department of Neurosurgery, KyungHee University Hospital, Seoul, Korea
| | - Seung Hwan Lee
- Department of Neurosurgery, KyungHee University Hospital at Gangdong, Seoul, Korea
| | - Jun Seok Koh
- Department of Neurosurgery, KyungHee University Hospital at Gangdong, Seoul, Korea
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Re-exploration of the craniotomy after surgical treatment of unruptured intracranial aneurysms. Acta Neurochir (Wien) 2014; 156:869-77. [PMID: 24682633 DOI: 10.1007/s00701-014-2059-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 03/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Unplanned re-exploration of the craniotomy after surgical treatment of unruptured intracranial aneurysms (UIAs) is sometimes required, but the underlying causes and rates of these procedures are seldom reported. This study retrospectively analyzed the causes of such re-explorations to identify methods for decreasing their necessity. METHOD From January 2000 to December 2011, 1,720 patients with a total of 1,938 UIAs underwent surgical treatment at our institution. From this cohort, 26 patients (1.5 %) with 38 UIAs required re-exploration. Clinical data, aneurysm characteristics, treatment methods, and the incidence and causes of re-exploration of the craniotomy were analyzed for these 26 patients. RESULTS Several causes of re-exploration were identified: compromised distal blood flow (eight patients, 0.47 %), hemorrhagic venous infarction (four patients, 0.23 %), brain retraction injury (three patients, 0.17 %), newly identified aneurysms (three patients, 0.17 %), bleeding from an incompletely clipped aneurysm (two patients, 0.12 %), epidural hematoma (two patients, 0.12 %), failed aneurysm clipping (two patients, 0.12 %) and other causes (two patients, 0.12 %). Annual re-exploration incidence rates ranged from 0 to 3.1 %. Annual incidence rates gradually decreased following the introduction of several intraoperative monitoring systems. CONCLUSIONS Precise surgical planning and careful operative techniques can reduce the incidence of unplanned re-exploration of the craniotomy. The introduction of various intraoperative monitoring systems can also contribute to a reduction in this incidence.
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21
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Kulwin C, Cohen-Gadol AA. False-negative indocyanine green videoangiography among complex unruptured middle cerebral artery aneurysms: the importance of further aneurysm inspection. Br J Neurosurg 2014; 28:658-62. [PMID: 24552255 DOI: 10.3109/02688697.2014.889811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Successful surgical treatment of cerebral aneurysms requires complete occlusion of the aneurysm lumen while maintaining patency of the adjacent branching and perforating arteries. Intraoperative flow assessment allows aneurysm clip repositioning in the event these requirements are not met, avoiding the risk of postoperative rehemorrhage or infarction. A number of modalities have been proposed for primarily intraoperative qualitative blood flow assessment, including microdoppler ultrasonography, intraoperative digital subtraction angiography (DSA), and more recently noninvasive fluorescent angiography including indocyanine green (ICG) fluorescent imaging. Puncture of the aneurysm dome to exclude aneurysm sac filling may also assess the efficacy of clip placement. Although a high concordance between ICG and DSA has been reported, there remains an important subset of aneurysms for which negative ICG study may erroneously suggest aneurysm occlusion. A high-risk situation for such a false-negative study is an atherosclerotic middle cerebral artery (MCA) aneurysm in which vessel wall plaque interferes with the ICG signal. Furthermore, a decreased flow within the aneurysm may not allow enough emission light for detection under the current technology. In this report, we describe our experience with cases of MCA aneurysms with false-negative ICG-VA studies requiring clip adjustment for optimal surgical treatment and discuss two illustrative cases of MCA aneurysms with intraoperative fluorescence studies that were falsely negative, requiring puncture of the aneurysm to correctly identify incomplete aneurysm occlusion.
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Affiliation(s)
- Charles Kulwin
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indiana University , Indianapolis, IN , USA
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Seule MA, Stienen MN, Gautschi OP, Richter H, Desbiolles L, Leschka S, Hildebrandt G. Surgical treatment of unruptured intracranial aneurysms in a low-volume hospital--outcome and review of literature. Clin Neurol Neurosurg 2012; 114:668-72. [PMID: 22300889 DOI: 10.1016/j.clineuro.2011.12.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Revised: 11/27/2011] [Accepted: 12/21/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to evaluate surgical outcome of unruptured intracranial aneurysms (UIAs) in a low-volume hospital and compare the results with the recent literature. METHODS A retrospective review of all consecutive craniotomies for UIA from July 1999 through June 2009 was performed. Morbidity was defined as modified Rankin Scale (mRS) ≥ 3 and evaluated six weeks after surgery. Cognitive function was evaluated at rehabilitation-to-home discharge. A PubMed database search (2001-2011) seeking retrospective, single-center studies reporting on surgical outcome of UIAs was performed. RESULTS There were 47 procedures performed in 42 patients to treat 50 UIAs (mean of 5 annual craniotomies). The mean age was 54.7 ± 12.1 years and mean aneurysm size was 7.6 ± 4.0mm. Favorable outcome (mRS 0-2) at six weeks after surgery was achieved in 45 of 47 procedures (95.7%). Aneurysm size ≥ 12 mm was statistically significant related to adverse outcome defined as mRS change ≥ 1 (71% vs. 29%; p = 0.018). Five patients (10.6%) with favorable neurological outcome (mRS 2) presented with cognitive impairment at rehabilitation-to-home discharge. There was no significant difference in overall morbidity and mortality comparing low- and high-volume hospitals (4.0% vs. 4.8%; p = 0.85). CONCLUSIONS Low-volume hospitals may achieve good results for surgical treatment of UIAs. The results indicate that defining numeric operative volume thresholds is not feasible to guide centralization of aneurysm treatment.
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Affiliation(s)
- M A Seule
- Department of Neurosurgery, Kantonsspital St Gallen, St Gallen, Switzerland.
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