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Kim BG, Jeon YT, Han J, Bae YK, Lee SU, Ryu JH, Koo CH. The Neuroprotective Effect of Thiopental on the Postoperative Neurological Complications in Patients Undergoing Surgical Clipping of Unruptured Intracranial Aneurysm: A Retrospective Analysis. J Clin Med 2021; 10:jcm10061197. [PMID: 33809302 PMCID: PMC7999640 DOI: 10.3390/jcm10061197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/04/2021] [Accepted: 03/11/2021] [Indexed: 11/16/2022] Open
Abstract
Although thiopental improved neurological outcomes in several animal studies, there are still insufficient clinical data examining the efficacy of thiopental for patients undergoing surgical clipping of unruptured intracranial aneurysm (UIA). This study validated the effect of thiopental and investigated risk factors associated with postoperative neurological complications in patients undergoing surgical clipping of UIA. In total, 491 patients who underwent aneurysm clipping were included in this retrospective cohort study. Data regarding demographics, aneurysm characteristics, and use of thiopental were collected from electronic medical records. Propensity score matching and logistic regression analysis were used. After propensity score matching, the thiopental group showed a lower incidence of the postoperative neurological complications than non-thiopental group (5.5% vs. 17.1%, p = 0.001). In multivariate analysis, thiopental reduced the risk of postoperative neurological complications (odds ratio (OR) 0.26, 95% confidence interval (CI) 0.13 to 0.51, p < 0.001) while aneurysm size ≥ 10 mm (OR 4.48, 95% CI 1.69 to 11.87, p = 0.003), and hyperlipidemia (OR 2.24, 95% CI 1.16 to 4.32, p = 0.02) increased the risk of postoperative neurological complications. This study showed that thiopental was associated with the lower risk of neurological complications after clipping of UIA.
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Affiliation(s)
- Byung-Gun Kim
- Department of Anesthesiology and Pain Medicine, Inha University School of Medicine, Inha University Hospital, Incheon 22332, Korea;
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; (Y.-T.J.); (J.-H.R.)
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.H.); (Y.K.B.)
| | - Jiwon Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.H.); (Y.K.B.)
| | - Yu Kyung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.H.); (Y.K.B.)
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam 13620, Korea;
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea; (Y.-T.J.); (J.-H.R.)
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.H.); (Y.K.B.)
| | - Chang-Hoon Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.H.); (Y.K.B.)
- Correspondence: ; Tel.: +82-31-787-7497; Fax: +82-31-787-4063
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Kienzler JC, Diepers M, Marbacher S, Remonda L, Fandino J. Endovascular Temporary Balloon Occlusion for Microsurgical Clipping of Posterior Circulation Aneurysms. Brain Sci 2020; 10:brainsci10060334. [PMID: 32486121 PMCID: PMC7349693 DOI: 10.3390/brainsci10060334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/15/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022] Open
Abstract
Based on the relationship between the posterior clinoid process and the basilar artery (BA) apex it may be difficult to obtain proximal control of the BA using temporary clips. Endovascular BA temporary balloon occlusion (TBO) can reduce aneurysm sac pressure, facilitate dissection/clipping, and finally lower the risk of intraoperative rupture. We present our experience with TBO during aneurysm clipping of posterior circulation aneurysms within the setting of a hybrid operating room (hOR). We report one case each of a basilar tip, posterior cerebral artery, and superior cerebellar artery aneurysm that underwent surgical occlusion under TBO within an hOR. Surgical exposure of the BA was achieved with a pterional approach and selective anterior and posterior clinoidectomy. Intraoperative digital subtraction angiography (iDSA) was performed prior, during, and after aneurysm occlusion. Two patients presented with subarachnoid hemorrhage and one patient presented with an unruptured aneurysm. The intraluminal balloon was inserted through the femoral artery and inflated in the BA after craniotomy to allow further dissection of the parent vessel and branches needed for the preparation of the aneurysm neck. No complications during balloon inflation and aneurysm dissection occurred. Intraoperative aneurysm rupture prior to clipping did not occur. The duration of TBO varied between 9 and 11 min. Small neck aneurysm remnants were present in two cases (BA and PCA). Two patients recovered well with a GOS 5 after surgery and one patient died due to complications unrelated to surgery. Intraoperative TBO within the hOR is a feasible and safe procedure with no additional morbidity when using a standardized protocol and setting. No relevant side effects or intraoperative complications were present in this series. In addition, iDSA in an hOR facilitates the evaluation of the surgical result and 3D reconstructions provide documentation of potential aneurysm remnants for future follow-up.
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Affiliation(s)
- Jenny C. Kienzler
- Department of Neurosurgery, Kantonsspital Aarau, CH-5000 Aarau, Switzerland; (J.C.K.); (S.M.)
| | - Michael Diepers
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, 5000 Aarau, Switzerland; (M.D.); (L.R.)
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, CH-5000 Aarau, Switzerland; (J.C.K.); (S.M.)
| | - Luca Remonda
- Division of Neuroradiology, Department of Radiology, Kantonsspital Aarau, 5000 Aarau, Switzerland; (M.D.); (L.R.)
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, CH-5000 Aarau, Switzerland; (J.C.K.); (S.M.)
- Correspondence: ; Tel.: +41-62-838-6692; Fax: +41-62-838-6629
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Tanabe J, Ishikawa T, Moroi J. Safe time duration for temporary middle cerebral artery occlusion in aneurysm surgery based on motor-evoked potential monitoring. Surg Neurol Int 2017; 8:79. [PMID: 28584682 PMCID: PMC5445649 DOI: 10.4103/sni.sni_410_16] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/20/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Temporary vessel occlusion of the parent artery is an essential technique for aneurysm surgery. Our aim was to clarify the safe time for temporary occlusion for aneurysm surgery, that is the "safe time duration" (STD), in which brain tissue exposed to ischemia will almost never fall into even the ischemic penumbra during temporary occlusion of the middle cerebral artery (MCA), and even transient postoperative motor impairment will be rare using intraoperative motor-evoked potentials (MEP). METHODS Twenty-four patients underwent MCA aneurysm clipping surgery with MEP monitoring for 13 ruptured aneurysms and 11 unruptured aneurysms. The duration of vessel occlusion in patients without MEP changes was measured as the STD. Average STD was calculated as 95% confidence interval for the population mean using sample data from patients with MEP changes and patients without changes. RESULTS All 24 patients received proximal flow control only. Five patients (20.8%) developed significant intraoperative MEP changes. Time to MEP change (i.e., STD) in these patients was 4.6 ± 2.1 min. In patients without MEP changes, STD was 2.7 ± 1.4 min. Average STD was thus 3.1 ± 0.7 min. CONCLUSIONS The 95% lower confidence limit for average STD was 2.4 min when applying temporary occlusion on the proximal side of the MCA. This STD resembled that previously reported for temporary proximal occlusion of the internal carotid artery.
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Affiliation(s)
- Jun Tanabe
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
| | - Junta Moroi
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
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Tanabe J, Ishikawa T, Moroi J, Suzuki A. Preliminary study on safe thresholds for temporary internal carotid artery occlusion in aneurysm surgery based on motor-evoked potential monitoring. Surg Neurol Int 2014; 5:47. [PMID: 24818054 PMCID: PMC4014813 DOI: 10.4103/2152-7806.130560] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 02/23/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The study aims were to clarify safe duration for temporary vessel occlusion of the internal carotid artery (ICA) during aneurysm surgery as exactly as possible. We examined safe time duration (STD), where brain tissue exposed to ischemia will never fall into even the ischemic penumbra using intraoperative motor-evoked potential (MEP). METHODS In 45 patients, temporary occlusion of the ICA was performed with MEP. We measured STD as the duration of temporary vessel occlusion during which MEP changes did not occur. To estimate average STD, we calculated the 95% confidence interval for the population mean from sample data for STD in patients with MEP changes and in patients without changes. RESULTS In the proximal-control group, 4 of 38 patients (10.5%) developed intraoperative MEP changes. In 4 patients, the time to MEP change (i.e. STD) was 6.0 ± 2.5 min. STD was 3.8 ± 1.6 min in the 34 patients without changes. The average STD was 4.0 ± 0.6 min. In the trap group (proximal and distal flow control), five of seven patients (60.0%) experienced intraoperative MEP changes (STD, 2.3 ± 1.0 min). All patients in the trap group who developed MEP changes showed involvement of the anterior choroidal artery (AchA) in the trapped segment. Average STD was 2.3 ± 1.1 min when trapping involving the AchA. CONCLUSIONS Although the study is preliminary based on the limited number of the patients, the 95% upper confidence limit for average STD was 4.6 min when the ICA was occluded proximal to the aneurysm, 3.4 min when the ICA was trapped involving the AchA.
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Affiliation(s)
- Jun Tanabe
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, 6-10 Senshu-Kubota-Machi, Akita, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, 6-10 Senshu-Kubota-Machi, Akita, Japan
| | - Junta Moroi
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, 6-10 Senshu-Kubota-Machi, Akita, Japan
| | - Akifumi Suzuki
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, 6-10 Senshu-Kubota-Machi, Akita, Japan
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Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract 2014; 2014:595837. [PMID: 24723946 PMCID: PMC3958760 DOI: 10.1155/2014/595837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 01/26/2014] [Indexed: 01/08/2023] Open
Abstract
Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention.
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Ishikawa T. What is the role of clipping surgery for ruptured cerebral aneurysms in the endovascular era? A review of recent technical advances and problems to be solved. Neurol Med Chir (Tokyo) 2013; 50:800-8. [PMID: 20885114 DOI: 10.2176/nmc.50.800] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Craniotomy and clipping have been robust treatments for ruptured cerebral aneurysm for more than 50 years, with satisfactory overall outcomes. Technical advances, such as developments in microsurgical tools and equipment, adjunctive therapy, and novel monitoring methods enable safer and more efficient treatment. However, overall surgical results have not shown any major improvements, as outcomes are mainly determined by the damage from initial bleeding, and new treatment strategies are not always free from associated complications and problems. Recent advances in endovascular treatment are shifting the treatment for ruptured cerebral aneurysm from craniotomy and clipping to intravascular coil embolization. However, craniotomy and clipping are very important for the treatment of ruptured cerebral aneurysm. This paper discusses recent advances and future perspectives in the field of clipping surgery for ruptured aneurysms.
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Affiliation(s)
- Tatsuya Ishikawa
- Department of Neurological Surgery, Research Institute for Brain and Blood Vessels-Akita, 6-10 Senshu-Kubota-machi, Akita, Japan.
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Wong JM, Ziewacz JE, Ho AL, Panchmatia JR, Kim AH, Bader AM, Thompson BG, Du R, Gawande AA. Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery. Neurosurg Focus 2013; 33:E15. [PMID: 23116095 DOI: 10.3171/2012.7.focus12181] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT As part of a project to devise evidence-based safety interventions for specialty surgery, we sought to review current evidence concerning the frequency of adverse events in open cerebrovascular neurosurgery and the state of knowledge regarding methods for their reduction. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. METHODS The authors performed a PubMed search using search terms "cerebral aneurysm", "cerebral arteriovenous malformation", "intracerebral hemorrhage", "intracranial hemorrhage", "subarachnoid hemorrhage", and "complications" or "adverse events." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the reported adverse events. RESULTS The review revealed hemorrhage-related hyperglycemia (incidence rates ranging from 27% to 71%) and cerebral salt-wasting syndromes (34%-57%) to be the most common perioperative adverse events related to subarachnoid hemorrhage (SAH). Next in terms of frequency was new cerebral infarction associated with SAH, with a rate estimated at 40%. Many techniques are advocated for use during surgery to minimize risk of this development, including intraoperative neurophysiological monitoring, but are not universally used due to surgeon preference and variable availability of appropriate staffing and equipment. The comparative effectiveness of using or omitting monitoring technologies has not been evaluated. The incidence of perioperative seizure related to vascular neurosurgery is unknown, but reported seizure rates from observational studies range from 4% to 42%. There are no standard guidelines for the use of seizure prophylaxis in these patients, and there remains a need for prospective studies to support such guidelines. Intraoperative rupture occurs at a rate of 7% to 35% and depends on aneurysm location and morphology, history of rupture, surgical technique, and surgeon experience. Preventive strategies include temporary vascular clipping. Technical adverse events directly involving application of the aneurysm clip include incomplete aneurysm obliteration and parent vessel occlusion. The rates of these events range from 5% to 18% for incomplete obliteration and 3% to 12% for major vessel occlusion. Intraoperative angiography is widely used to confirm clip placement; adjuncts include indocyanine green video angiography and microvascular Doppler ultrasonography. Use of these technologies varies by institution. DISCUSSION A significant proportion of these complications may be avoidable through development and testing of standardized protocols to incorporate monitoring technologies and specific technical practices, teamwork and communication, and concentrated volume and specialization. Collaborative monitoring and evaluation of such protocols are likely necessary for the advancement of open cerebrovascular neurosurgical quality.
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Affiliation(s)
- Judith M Wong
- Department of Health Policy and Management, Harvard School of Public Health, Brigham and Women’s Hospital, Street, Boston, Massachusetts 02115, USA
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Kim TK, Park IS. Comparative Study of Brain Protection Effect between Thiopental and Etomidate Using Bispectral Index during Temporary Arterial Occlusion. J Korean Neurosurg Soc 2011; 50:497-502. [PMID: 22323935 DOI: 10.3340/jkns.2011.50.6.497] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 11/09/2011] [Accepted: 12/19/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study was conducted to compare the effect of etomidate with that of thiopental on brain protection during temporary vessel occlusion, which was measured by burst suppression rate (BSR) with the Bispectral Index (BIS) monitor. METHODS Temporary parent artery occlusion was performed in forty one patients during cerebral aneurysm surgery. They were randomly assigned to one of two groups. General anesthesia was induced and maintained with 1.5-2.5 vol% sevoflurane and 50% N(2)O. The pharmacological burst suppression (BS) was induced by a bolus injection of thiopental (5 mg/kg, group T) or etomidate (0.3 mg/kg, group E) according to randomization prior to surgery. After administration of drugs, the hemodynamic variables, the onset time of BS, the numerical values of BIS and BSR were recorded at every minutes. RESULTS There were no significant differences of the demographics, the BIS numbers and the hemodynamic variables prior to injection of drugs. The durations of burst suppression in group E (11.1±6.8 min) were not statistically different from that of group T (11.1±5.6 min) and nearly same pattern of burst suppression were shown in both groups. More phenylephrine was required to maintain normal blood pressure in the group T. CONCLUSION Thiopental and etomidate have same duration and a similar magnitude of burst suppression with conventional doses during temporary arterial occlusion. These findings suggest that additional administration of either drug is needed to ensure the BS when the temporary occlusion time exceed more than 11 minutes. Etomidate can be a safer substitute for thiopental in aneurysm surgery.
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Affiliation(s)
- Tae Kwan Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
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Ha SK, Lim DJ, Seok BG, Kim SH, Park JY, Chung YG. Risk of stroke with temporary arterial occlusion in patients undergoing craniotomy for cerebral aneurysm. J Korean Neurosurg Soc 2009; 46:31-7. [PMID: 19707491 DOI: 10.3340/jkns.2009.46.1.31] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 06/02/2009] [Accepted: 06/02/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study was performed to elucidate the technical and patient-specific risk factors for postoperative ischemia in patients undergoing temporary arterial occlusion (TAO) during the surgical repair of their aneurysms. METHODS Eighty-nine consecutive patients in whom TAO was performed during surgical repair of an aneurysm were retrospectively analyzed. The demographics of the patients were analyzed with respect to age, Hunt and Hess grade on admission, Fisher grade of hemorrhage, aneurysm characteristics, timing of surgery, duration of temporary occlusion, and number of temporary occlusive episodes. Outcome was analyzed at the 3-month follow-up, along with the occurrence of symptomatic and radiological stroke. RESULTS In overall, twenty-seven patients (29.3%) had radiologic ischemia attributable to TAO and fifteen patients (16.3%) had symptomatic ischemia attributable to TAO. Older age and poor clinical grade were associated with poor clinical outcome. There was a significantly higher rate of symptomatic ischemia in patients who underwent early surgery (p = 0.007). The incidence of ischemia was significantly higher in patients with TAO longer than 10 minutes (p = 0.01). In addition, patients who underwent repeated TAO, which allowed reperfusion, had a lower incidence of ischemia than those who underwent single TAO lasting for more than 10 minutes (p = 0.011). CONCLUSION Duration of occlusion is the only variable that needs to be considered when assessing the risk of postoperative ischemic complication in patients who undergo temporary vascular occlusion. Attention must be paid to the patient's age, grade of hemorrhage, and the timing of surgery. In addition, patients undergoing dissection when brief periods of temporary occlusion are performed may benefit more from intermittent reperfusion than continuous clip application. With careful planning, the use of TAO is a safe technique when used for periods of less than 10 minutes.
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Affiliation(s)
- Sung-Kon Ha
- Department of Neurosurgery, Korea University Medical Center, Seoul, Korea
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Hauck EF, Wei J, Quast MJ, Nauta HJW. A new technique allowing prolonged temporary cerebral artery occlusion. J Neurosurg 2008; 109:1127-33. [PMID: 19035732 DOI: 10.3171/jns.2008.109.12.1127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Clipping of complex cerebral aneurysms often requires temporary vessel occlusion. The risk of stroke, however, increases exponentially with occlusion time. The authors hypothesized that prolonged temporary occlusion might be tolerated if the occluded vessels were perfused with cold physiological saline solution (CPSS). A low-flow perfusion rate would permit surgical manipulation of an aneurysm distal to the occlusion. METHODS To test this hypothesis, the authors temporarily occluded the middle cerebral artery (MCA) with an endovascular catheter in 6 rats. Three animals, the treatment group, were perfused with 5-ml CPSS/hour through the occluding endovascular catheter into the MCA, and the other 3 served as an ischemic control group. In both groups, the catheter was removed after 90 minutes of occlusion. The brain temperature was monitored with a stereotactically placed probe in the caudate-putamen in 2 separate experimental groups (11 animals). RESULTS Magnetic resonance imaging perfusion scanning during vessel occlusion confirmed similar reduction of cerebral blood flow during MCA occlusion in both the simple-occlusion and perfusion-occlusion groups. Magnetic resonance imaging diffusion scans performed 24 hours after temporary occlusion revealed infarcts in the ischemic control group of 138.3 +/- 28.0 mm(3) versus 9.9 +/- 9.9 mm(3) in the cold saline group (p < 0.005). A focal cooling effect during perfusion with CPSS was demonstrated (p < 0.05). CONCLUSIONS Prolonged temporary cerebral vessel occlusion can be tolerated using superselective CPSS perfusion through an occluding endovascular catheter into the ischemic territory. This technique could possibly be applied in neurosurgery practice to the management of complex intracranial aneurysms.
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Affiliation(s)
- Erik F Hauck
- Division of Neurosurgery, University of Texas Medical Branch at Galveston, Texas, USA.
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Chong JY, Kim DW, Jwa CS, Yi HJ, Ko Y, Kim KM. Impact of cardio-pulmonary and intraoperative factors on occurrence of cerebral infarction after early surgical repair of the ruptured cerebral aneurysms. J Korean Neurosurg Soc 2008; 43:90-6. [PMID: 19096611 DOI: 10.3340/jkns.2008.43.2.90] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Accepted: 02/11/2008] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Delayed ischemic deficit or cerebral infarction is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study is to reassess the prognostic impact of intraoperative elements, including factors related to surgery and anesthesia, on the development of cerebral infarction in patients with ruptured cerebral aneurysms. METHODS Variables related to surgery and anesthesia as well as predetermined factors were all evaluated via a retrospective study on 398 consecutive patients who underwent early microsurgery for ruptured cerebral aneurysms in the last 7 years. Patients were dichotomized as following; good clinical grade (Hunt-Hess grade I to III) and poor clinical grade (IV and V). The end-point events were cerebral infarctions and the clinical outcomes were measured at postoperative 6 months. RESULTS The occurrence of cerebral infarction was eminent when there was an intraoperative rupture, prolonged temporary clipping and retraction time, intraoperative hypotension, or decreased O(2) saturation, but there was no statistical significance between the two different clinical groups. Besides the Fisher Grade, multiple logistic regression analyses showed that temporary clipping time, hypotension, and low O(2) saturation had odds ratios of 1.574, 3.016, and 1.528, respectively. Cerebral infarction and outcome had a meaningful correlation (gamma=0.147, p=0.038). CONCLUSION This study results indicate that early surgery for poor grade SAH patients carries a significant risk of ongoing ischemic complication due to the brain's vulnerability or accompanying cardio-pulmonary dysfunction. Thus, these patients should be approached very cautiously to overcome any anticipated intraoperative threat by concerted efforts with neuro-anesthesiologist in point to point manner.
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Affiliation(s)
- Jong-Yun Chong
- Department of Neurosurgery , Hanyang University Medical Center, Seoul, Korea
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Calderon-Arnulphi M, Alaraj A, Amin-Hanjani S, Mantulin WW, Polzonetti CM, Gratton E, Charbel FT. Detection of cerebral ischemia in neurovascular surgery using quantitative frequency-domain near-infrared spectroscopy. J Neurosurg 2007; 106:283-90. [PMID: 17410713 DOI: 10.3171/jns.2007.106.2.283] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECT There is great value in monitoring for signs of ischemia during neurovascular procedures. Current intraoperative monitoring techniques provide real-time feedback with limited accuracy. Quantitative frequency-domain near-infrared spectroscopy (Q-NIRS) allows measurement of tissue oxyhemoglobin (HbO2), deoxyhemoglobin (HHb), and total hemoglobin (tHb) concentrations and brain tissue oxygen saturation (SO2), which could be useful when monitoring for evidence of intraoperative ischemia. METHODS Using Q-NIRS, the authors monitored 25 neurovascular procedures including aneurysm clip placement, arteriovenous malformation resection, carotid endarterectomy, superficial temporal artery-middle cerebral artery (MCA) bypass surgery, external carotid artery-MCA bypass surgery, encephaloduromyosynangiosis, and balloon occlusion testing. The Q-NIRS technology provides measurable cerebral oxygenation values independent from those of the scalp tissue. Thus, alterations in the variables measured with Q-NIRS quantitatively reflect cerebral tissue perfusion. Bilateral monitoring was performed in all cases. Five of the patients exhibited evidence of clinical ischemic events during the procedures. One patient suffered blood loss with systemic hypotension and developed diffuse brain edema intraoperatively, one patient suffered an ischemic event intraoperatively and developed an occipital stroke postoperatively, and one patient showed slowing on electroencephalography intraoperatively during carotid clamping; in two patients balloon occlusion testing failed. In all cases of ischemic events occurring during the procedure, Q-NIRS monitoring showed a decrease in HbO2, tHb, and SO2, and an increase in HHb. CONCLUSIONS . Quantitative frequency-domain near-infrared spectroscopy provides quantifiable and continuous real-time information about brain oxygenation and hemodynamics in a noninvasive manner. This continuous intraoperative oxygenation monitoring is a promising method for detecting ischemic events during neurovascular procedures.
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Affiliation(s)
- Mateo Calderon-Arnulphi
- Department of Neurosurgery, University of Illinois at Chicago Medical Center, Chicago 60612, USA
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Akyuz M, Erylmaz M, Ozdemir C, Goksu E, Ucar T, Tuncer R. Effect of temporary clipping on frontal lobe functions in patients with ruptured aneurysm of the anterior communicating artery. Acta Neurol Scand 2005; 112:293-7. [PMID: 16218910 DOI: 10.1111/j.1600-0404.2005.00483.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND After surgery for ruptured anterior communicating artery (ACoA) aneurysm, several patients who have achieved a favorable neurological outcome yet have been observed to suffer from a poor cognitive outcome. The aim of this study was to explore the possible effects of temporary clip applications on frontal lobe functions in the patients with ruptured ACoA aneurysm. METHODS Forty patients were chosen among a series of cases who underwent an early surgery (within 96 h) after ACoA aneurysm bleeding. All of them were in Hunt-Hess grade 1 or grade 2. Of the 40 patients, temporary clipping was used in 22 patients (group A), whereas it was not used in 18 patients (group B). These two groups were compared with 20 volunteers (group C) without neurologic or psychiatric disorders. RESULTS The mean duration of temporary vessel occlusion for both A1 was 8.2 +/- 2.9 min (4-15) in group A. Neither clinical nor radiographic strokes were detected. An improvement in frontal lobe function occurred at long term in group B patients. Whereas, cognitive deficits were persisting at long-term follow-up in group A, especially in patients who had temporary clipping duration longer than 9 min. CONCLUSIONS The results emphasize that the negative effects of temporary vessel occlusion on cognitive changes occur before ischemic damage. Thus, such negative effects of temporary clipping on cognitive functions should not be neglected by surgeons during surgery.
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Affiliation(s)
- M Akyuz
- Department of Neurosurgery, Akdeniz University Medical School, Antalya, Turkey
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ISHIKAWA T, KAMIYAMA H, KAZUMATA K, NAKAYAMA N, YOSHIMOTO T, KURODA S, IWASAKI Y. Anatomy and Surgery for Internal Carotid Aneurysm at the Bifurcation of the Posterior Communicating Artery. ACTA ACUST UNITED AC 2004. [DOI: 10.7887/jcns.13.382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Tatsuya ISHIKAWA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | | | - Ken KAZUMATA
- Department of Neurosurgery, Asahikawa Red-Cross Hospital
| | | | | | - Satoshi KURODA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Yoshinobu IWASAKI
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
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Castro E, Villoria F, Fortea F, Carrera J, Mateo O, Sanchez-Alarcos S, Reparaz L. Simultaneous Cerebral Aneurysms and Carotid Disease Should the Symptomatic Lesion always be the first to be Treated? A Case Report. Interv Neuroradiol 2003; 9:213-8. [PMID: 20591273 DOI: 10.1177/159101990300900212] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2003] [Accepted: 04/04/2003] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Simultaneous presentation of carotid stenosis and cerebral aneurysms is rare and it is conventionally accepted that symptomatic lesions need to be treated first. Our purpose was to describe our experience in managing patients who simultaneously presented significant carotid stenosis and cerebral aneurysm.
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Affiliation(s)
- E Castro
- Department of Neuroradiology, Hospital Gregorio Marañón; Madrid, Spain -
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Ragonović Z, Pavlicević G. [Intraoperative rupture of cerebral aneurysms and use of temporary arterial occlusion]. VOJNOSANIT PREGL 2002; 59:125-30. [PMID: 12053463 DOI: 10.2298/vsp0202125r] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The aim was to analyze the risk factors for intraoperative rupture (IR) of cerebral aneurysm and for temporary clips (TC) use, as well as their influence on the final postoperative outcome. METHODS Retrospective study was done 72 IR patients, and on 75 TC patients. For patients with or without IR, as well as for the patients with or without TK, outcome of the treatment, aneurysm size and localization, preoperative clinical state and operative timing was analyzed, and statistical significance of obtained differences was tested. RESULTS IR occurred in 40% of anterior cerebral artery aneurysms and in 16.7% of internal carotid artery aneurysms (p > 0.05), while TCs were used in 52% of middle cerebral artery aneurysms and 34.8% of internal carotid artery aneurysms (p > 0.05). Average size was 17.3 mm for aneurysms with IR and 11.7 mm for those without IR (p > 0.05). Aneurysms were significantly larger in patients with TCs, than in patients without TCs (16.7 mm and 9.4 mm respectively, p < 0.05). Preoperative period was 10.2 days for patients with IR, and 16.8 days for patients without IR (p < 0.05). Favorable outcome was observed in 71.4% of patients with IR and in 70.6% of those without IR, as well as in 76.4% of patients who required TC and in 75.6% of cases without TC (p > 0.05). Average duration of temporary occlusion was 5.8 min for patients with favorable outcome and 15 min for patients with poor outcome (p < 0.05). CONCLUSIONS Incidence of IR mostly depended on the duration of preoperative interval, while the frequency of TC use depended mostly on aneurysm size. IR did not influence the surgical outcome, as well as TC use, if the occlusion was shorter than 8-10 min.
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