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Han HJ, Chung KS, Kim S, Kim JJ, Park KY, Kim YB. Incidence and Characteristics of Cerebral Infarction After Microsurgical Clipping of Unruptured Anterior Circulation Cerebral Aneurysms: Diffusion-Weighted Imaging-Based Analysis of 600 Patients. Neurosurgery 2024:00006123-990000000-01217. [PMID: 38869271 DOI: 10.1227/neu.0000000000003038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/25/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Postclipping cerebral infarction (PCI) remains a major concern after treatment for unruptured intracranial aneurysms (UIAs). However, studies of microsurgical clipping based on diffusion-weighted imaging are limited. We aimed to present the incidence, risk factors, and types of PCI and its radiological and clinical characteristics. METHODS This was a retrospective single-center study in which patients were scheduled to undergo microsurgical clipping for anterior circulation UIAs. The overall incidence and risk factors were calculated. Based on the operation and relevant artery, we categorized PCI on diffusion-weighted imaging into 4 types and presented their radiological and clinical characteristics. RESULTS We reviewed the radiological and clinical data of 605 patients. The overall incidence of PCI was 16.7% (101/605), of which asymptomatic infarction was 14.9% (90/605) and symptomatic infarction was 1.8% (11/605). Hypertension (adjusted odds ratio [aOR], 2.258; 95% confidence interval [CI]: 1.330-3.833), temporary clipping (aOR, 1.690; 95% CI: 1.034-2.760), multiple aneurysm locations (aOR, 1.832; 95% CI: 1.084-3.095), and aneurysm dome size (aOR, 1.094; 95% CI: 1.006-1.190) were independent risk factors for PCI. Type II (perianeurysmal perforator) infarction was the most common type of PCI (48.6%) and the most common cause of symptomatic infarction (72.7%). Types II and III (distal embolic) infarctions correlated with atherosclerotic changes in the aneurysm wall and temporary clipping (62.4% and 70.6%, respectively). The type IV (unrelated) infarction group had a higher incidence of systemic atherosclerosis (55%). CONCLUSION Microsurgical clipping is a safe and viable option for the treatment of anterior circulation UIAs. However, modification of the surgical technique, preoperative radiological assessment, and patient selection are required to reduce the incidence of PCI.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kim KU, Kim JJ, Park KY, Kim YB, Han HJ. Endoscope-assisted microsurgical clipping and reduction of post-clipping cerebral infarction: historical comparison using diffusion-weighted images. Neurosurg Rev 2023; 46:106. [PMID: 37145191 DOI: 10.1007/s10143-023-02020-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/09/2023] [Accepted: 05/01/2023] [Indexed: 05/06/2023]
Abstract
Endoscopic assistance for aneurysm clipping and its possible benefits have been suggested in previous studies, but its clinical significance has not been fully elucidated. This study aimed to present the efficacy of endoscopy-assisted clipping in reducing post-clipping cerebral infarction (PCI) and clinical outcomes via a historical comparison of patients in our institution from January 2020 to March 2022. A total of 348 patients were included, 189 of whom underwent endoscope-assisted clipping. The overall incidence of PCI was 10.9% (n = 38); it was 15.7% (n = 25) before applying endoscopic assistance and decreased to 6.9% (n = 13) after endoscope application (p = 0.010). The application of a temporary clip (odds ratio [OR]: 2.673, 95% confidence interval [CI]: 1.291-5.536), history of hypertension (OR: 2.176, 95% CI: 0.897-5.279), history of diabetes mellitus (OR: 2.530, 95% CI: 1.079-5.932), and current smoker (OR: 3.553, 95% CI: 1.288-9.802) were independent risk factors of PCI, whereas endoscopic assistance was an independent inverse risk factor (OR: 0.387, 95% CI: 0.182-0.823). Compared to the location of the unruptured intracranial aneurysms, internal carotid artery aneurysms showed a significant decrease in the incidence of PCI (5.8% vs. 22.9%, p = 0.019). In terms of clinical outcomes, PCI was a significant risk factor for longer admission duration, intensive care unit stay, and poor clinical outcomes. However, endoscopic assistance itself was not a significant risk factor for clinical outcomes on the 45-day modified Rankin Scale. In this study, we noted the clinical significance of endoscope-assisted clipping in preventing PCI. These findings could reduce the incidence of PCI and improve the understanding of its mechanisms of action. However, a larger and longer-term study is required to evaluate the benefits of endoscopy on clinical outcomes.
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Affiliation(s)
- Kang U Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Jae Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Hyun Jin Han
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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3
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Noda K, Koga M, Toyoda K. Recognition of Strokes in the ICU: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040182. [PMID: 37103061 PMCID: PMC10145112 DOI: 10.3390/jcdd10040182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.
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Affiliation(s)
- Kotaro Noda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
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4
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Grasso G, Torregrossa F, Cohen-Gadol AA. Avoiding Complications in Aneurysm Ligation: Operative Tips and Tricks. World Neurosurg 2022; 159:259-265. [PMID: 35255627 DOI: 10.1016/j.wneu.2021.10.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/24/2022]
Abstract
Preventing possible complications during brain aneurysm surgery is mandatory to ensure a better outcome for patients. Currently, it is possible to rely on some technologic innovations such as motor evoked potential, endoscope-assisted surgery, dye with indocyanine green, and video angiography capable of supporting the surgeon's work. The innovation process has mainly assisted the endovascular technique compared with surgery. The latter, apart from some new technical expedients, always requires anatomic knowledge and optimal technical preparation. A careful patient selection, adequate surgical exposure, use of microsurgical techniques in expert hands, and meticulous postoperative management represent the key to success for the surgical treatment of cerebral aneurysms.
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Affiliation(s)
- Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy.
| | - Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Aaron A Cohen-Gadol
- Indiana University, Department of Neurosurgery and the Neurosurgical Atlas, Bloomington, Indiana, USA
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5
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Vogels V, Dammers R, van Bilsen M, Volovici V. Deep Cerebral Perforators: Anatomical Distribution and Clinical Symptoms: An Overview. Stroke 2021; 52:e660-e674. [PMID: 34311568 DOI: 10.1161/strokeaha.120.034096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The anatomic distribution of the deep cerebral perforators is considered either a given or subject to enormous variability. Most published overviews on this topic only report findings from a limited number of anatomic dissections, and no attempt has been made to date to provide a comprehensive overview of all published data. A comprehensive literature search was performed on MEDLINE, Embase, and Google Scholar with the help of an information specialist. Three types of studies were included: (1) articles that described the anatomy and distribution territories of perforator groups arising from the arteries of the circle of Willis; (2) studies that evaluated the anatomy of the deep cerebral perforators using imaging techniques; and (3) studies that evaluated either microsurgically or radiologically confirmed perforator occlusion and reported the (magnetic resonance imaging-confirmed) distribution territory of the infarction together with a description of the clinical symptoms associated as a result of the infarction. A total of 2715 articles were screened and 53 were included. Of these, 40 dealt with the anatomic and imaging anatomy of perforator groups (37 reported results of dissections and 3 results of imaging studies), with a total of 2421 hemispheres investigated. Another 13 articles with 680 patients were included that evaluated perforator infarction territories. The deep cerebral perforator distribution shows large variability with poor concordance rates among reported studies, with the exception of the posterior communicating and anterior choroidal artery perforators. Despite the assumption that cerebral perforator anatomy is a given, studies show large variability in the anatomic distribution of various perforator groups. Perforator anatomy and relationships between perforator groups, as well as potential collateral circulation in these territories should be prioritized as a research topic in cerebrovascular disease in the near future.
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Affiliation(s)
- Valerie Vogels
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC Rotterdam, the Netherlands (V.Vogels, R.D., V.Volovici).,Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands (M.v.B.)
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC Rotterdam, the Netherlands (V.Vogels, R.D., V.Volovici).,Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands (M.v.B.)
| | - Martine van Bilsen
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC Rotterdam, the Netherlands (V.Vogels, R.D., V.Volovici).,Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands (M.v.B.)
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC Rotterdam, the Netherlands (V.Vogels, R.D., V.Volovici).,Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands (M.v.B.)
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6
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Kumar S, Sahana D, Menon G. Optimal Use of Temporary Clip Application during Aneurysm Surgery - In Search of the Holy Grail. Asian J Neurosurg 2021; 16:237-242. [PMID: 34268145 PMCID: PMC8244713 DOI: 10.4103/ajns.ajns_465_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/29/2021] [Indexed: 11/04/2022] Open
Abstract
Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were "Temporary Clip," "Temporary Clipping," "Cerebral Aneurysm," and "Aneurysm." Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.
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Affiliation(s)
- Sanjeev Kumar
- Department of Neurosurgery, DKS Postgraduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Debabrata Sahana
- Department of Neurosurgery, DKS Postgraduate Institute and Research Center, Raipur, Chhattisgarh, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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7
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Basma J, Saad H, Abuelem T, Krisht K, Cai L, Pravdenkova S, Krisht AF. Anterior perforated substance region aneurysms: review of a series treated with microsurgical technique. Neurosurg Rev 2021; 44:2991-2999. [PMID: 33543414 DOI: 10.1007/s10143-021-01485-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 01/02/2021] [Accepted: 01/21/2021] [Indexed: 11/27/2022]
Abstract
Aneurysms arising from the distal carotid, proximal A1, and proximal M1 that project posteriorly and superiorly toward the anterior perforated substance (APS) are rare. Their open surgical treatment is particularly difficult due to poorly visualized origin of the aneurysm and the abundance of surrounding perforators. We sought to analyze the anatomical and clinical characteristics of APS aneurysms and discuss surgical nuances that can optimize visualization, complete neck clip obliteration, and preservation of adjacent perforators. Thirty-two patients with 36 APS aneurysms were surgically treated between November 2000 and September 2017. Patients were prospectively enrolled in a cerebral aneurysm database and their clinical, imaging, and surgical records were retrospectively reviewed. Twenty-seven aneurysms originated from the distal ICA, 7 from the proximal A1, and 2 from the proximal M1; 15 patients presented with subarachnoid hemorrhage. Careful intraoperative dissection revealed 4 aneurysms originating at the takeoff of a perforator; another 25 had at least 1 adherent perforator. All aneurysms were clipped except for one that was trapped. Postoperatively, 3 patients had radiographic infarctions in perforator territory with only 1 developing delayed clinical hemiparesis. Good outcome (modified Rankin Scale, 0-2) was achieved in 28 patients (88%). APS aneurysms present a challenging subset of aneurysms due to their complex anatomical relationship with surrounding perforators. These should be identified on preoperative imaging based on location and projection. Successful microsurgical clipping relies on optimization of the surgical view, meticulous clip reconstruction, preservation of all perforators, and electrophysiological monitoring to minimize ischemic complication.
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Affiliation(s)
- Jaafar Basma
- Arkansas Neuroscience Institute, CHI Saint Vincent Infirmary, Little Rock, AR, USA. .,Department of Neurosurgery, The University of Tennessee Health Science Center, 847 Monroe Avenue, Suite 427, Memphis, TN, 38163, USA.
| | - Hassan Saad
- Arkansas Neuroscience Institute, CHI Saint Vincent Infirmary, Little Rock, AR, USA
| | - Tarek Abuelem
- Arkansas Neuroscience Institute, CHI Saint Vincent Infirmary, Little Rock, AR, USA
| | - Khaled Krisht
- Arkansas Neuroscience Institute, CHI Saint Vincent Infirmary, Little Rock, AR, USA
| | - Li Cai
- Arkansas Neuroscience Institute, CHI Saint Vincent Infirmary, Little Rock, AR, USA
| | - Svetlana Pravdenkova
- Arkansas Neuroscience Institute, CHI Saint Vincent Infirmary, Little Rock, AR, USA
| | - Ali F Krisht
- Arkansas Neuroscience Institute, CHI Saint Vincent Infirmary, Little Rock, AR, USA
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8
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Rajappa D, Masapu D, Gopal S, Rudrappa S. Somatosensory Evoked Potentials as a Useful Tool to Limit the Temporary Clipping Time during Aneurysm Clipping. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1716946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Deepak Rajappa
- Division of Neuroanaesthesia, Department of Anaesthesia, Sakra World Hospital, Bengaluru, Karnataka, India
| | - Dheeraj Masapu
- Division of Neuroanaesthesia, Department of Anaesthesia, Sakra World Hospital, Bengaluru, Karnataka, India
| | - Swaroop Gopal
- Department of Neurosurgery, Sakra World Hospital, Bengaluru, Karnataka, India
| | - Satish Rudrappa
- Department of Neurosurgery, Sakra World Hospital, Bengaluru, Karnataka, India
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9
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Kumar P, Bodeliwala S, Aher R, Jagetia A, Srivastava AK, Singh D, Ganjoo P. Evaluation of Ischemia Following Clipping of Anterior Circulation Aneurysms with Respect to Temporary Clipping Using Diffusion-Weighted Magnetic Resonance Imaging: A Prospective Study. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0039-3402625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractTemporary vessel occlusion enables a surgeon dissect aneurysm and clip with a lower risk of intraoperative hemorrhage with the associated risk of ischemia. There are studies on permissible time of occlusion of the parent artery using temporary clip; however, the actual incidence of silent ischemic events in patients with aneurysms treated with microsurgical clipping is not well documented. We are trying to look for the association between temporary clipping and incidence of ischemia through this study. The study concluded the statistically significant association between the maximum time of single clip application and ischemia. Intermittent multiple temporary clippings can prevent ischemia instead of a single clipping of longer duration.
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Affiliation(s)
- Pankaj Kumar
- Department of Neurosurgery, Dr. Ram Manohar Lohia Hospital Hospital, New Delhi, India
| | - Shaam Bodeliwala
- Department of Neurosurgery, G.B. Pant Institute of Postgraduate Education and Research (GIPMER), New Delhi, India
| | - Rajender Aher
- Medipulse Hospital, Basni Phase II, Jodhpur, Rajasthan, India
| | - Anita Jagetia
- Department of Neurosurgery, G.B. Pant Institute of Postgraduate Education and Research (GIPMER), New Delhi, India
| | - Arvind Kumar Srivastava
- Department of Neurosurgery, G.B. Pant Institute of Postgraduate Education and Research (GIPMER), New Delhi, India
| | - Daljit Singh
- Department of Neurosurgery, G.B. Pant Institute of Postgraduate Education and Research (GIPMER), New Delhi, India
| | - Pragati Ganjoo
- Department of Neurosurgery, G.B. Pant Institute of Postgraduate Education and Research (GIPMER), New Delhi, India
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Goertz L, Hamisch C, Kabbasch C, Borggrefe J, Hof M, Dempfle AK, Lenschow M, Stavrinou P, Timmer M, Brinker G, Goldbrunner R, Krischek B. Impact of aneurysm shape and neck configuration on cerebral infarction during microsurgical clipping of intracranial aneurysms. J Neurosurg 2020; 132:1539-1547. [PMID: 30978687 DOI: 10.3171/2019.1.jns183193] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral infarction is a significant cause of morbidity and mortality related to microsurgical clipping of intracranial aneurysms. The objective of this study was to determine the impact of aneurysm shape and neck configuration on cerebral infarction after aneurysm surgery. METHODS The authors retrospectively reviewed consecutive cases of ruptured and unruptured aneurysms treated with microsurgical clipping at their institution between 2010 and 2018. Three-dimensional reconstructions from preoperative computed tomography and digital subtraction angiography were used to determine aneurysm shape (regular/complex) and neck configuration (regular/irregular). Morphological and procedure-related risk factors for cerebral infarction were identified using univariate and multivariate statistical analyses. RESULTS Among 243 patients with 252 aneurysms (148 ruptured, 104 unruptured), the overall cerebral infarction rate was 17.1%. Infarction tended to occur more often in aneurysms with complex shape (p = 0.084). Likewise, aneurysms with an irregular neck had a significantly higher rate of infarction (37.5%) than aneurysms with regular neck configuration (10.1%, p < 0.001). Aneurysms with an irregular neck were associated with a higher rate of intraoperative rupture (p = 0.003) and temporary parent artery occlusion (p = 0.037). In the multivariate analysis, irregular neck configuration was identified as an independent risk factor for infarction (OR 4.2, 95% CI 1.9-9.4, p < 0.001), whereas the association between aneurysm shape and infarction was not significant (p = 0.966). CONCLUSIONS Irregular aneurysm neck configuration represents an independent risk factor for cerebral infarction during microsurgical clipping of both ruptured and unruptured aneurysms.
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Affiliation(s)
| | | | | | - Jan Borggrefe
- 2Department of Neuroradiology, University Hospital of Cologne, Germany
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11
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Byoun HS, Oh CW, Kwon OK, Lee SU, Ban SP, Kim SH, Kim T, Bang JS, Kim SU, Choi J, Park KS. Intraoperative neuromonitoring during microsurgical clipping for unruptured anterior choroidal artery aneurysm. Clin Neurol Neurosurg 2019; 186:105503. [PMID: 31494461 DOI: 10.1016/j.clineuro.2019.105503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 08/18/2019] [Accepted: 08/26/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the safety and unexpected finding of the intraoperative neuromonitoring (IONM) including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during microsurgical clipping of an unruptured anterior choroidal artery (AChA) aneurysm. PATIENTS AND METHODS From January 2011 to March 2018, the neurophysiological, clinical, and radiological data of 115 patients who underwent microsurgical clipping for an unruptured AChA aneurysm under IONM were retrospectively analyzed. The incidence of ischemic complications after microsurgical clipping of unruptured AChA aneurysms as well as the false-negative rate, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IONM during surgery were calculated. RESULTS Ischemic complications after the microsurgical clipping of an AChA aneurysm under IONM occurred in 7 of 115 patients (6.08%). Among them, 3 were symptomatic (2.6%). The false-negative rate of IONM for ischemic complications was 6.08% (7 patients). High specificity; 100% (95% confidence interval [95% CI] = 0.972-1.000), PPVs; 100% (95% CI = 0.055-1.000), and NPVs; 93% (95% CI = 0.945-0.973) with low sensitivity; 11.1% (95% CI = 0.006-0.111) were calculated. CONCLUSIONS IONM including transcranial MEP during microsurgical clipping of unruptured AChA aneurysm might have limited usefulness. Therefore, other MEP monitoring using direct cortical stimulation or modified transcranial methodology should be considered to compensate for it.
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Affiliation(s)
- Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, South Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Sung Hoon Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
| | - Sung Un Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Jongsuk Choi
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
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12
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Kashkoush AI, Nguyen C, Balzer J, Habeych M, Crammond DJ, Thirumala PD. Diagnostic accuracy of somatosensory evoked potentials during intracranial aneurysm clipping for perioperative stroke. J Clin Monit Comput 2019; 34:811-819. [PMID: 31399827 DOI: 10.1007/s10877-019-00369-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/29/2019] [Indexed: 11/24/2022]
Abstract
Somatosensory evoked potentials (SSEPs) are utilized during aneurysm clipping to detect intraoperative ischemia. We assess the diagnostic accuracy of SSEPs in predicting perioperative stroke during aneurysm clipping. A retrospective review was conducted of 429 consecutive patients who underwent surgical clipping for ruptured and unruptured cerebral aneurysms with intraoperative SSEP monitoring from 2006 to 2013. The relationship between perioperative stroke and SSEP changes was analyzed by calculating the sensitivity, specificity, and area under a Receiving Operating Characteristic curve. Sensitivity and specificity were 42% and 90%, respectively. Area under the curve was 0.66 (95% confidence interval, 0.53-0.79). Reclassification of reversible temporary clip changes to correct for paradoxical classification of SSEP false positives raised the sensitivity from 42 to 65% (p = 0.041, Chi squared test). EEG (electroencephalography) changes increased the specificity (98% vs. 90%, p < 0.001, McNemar's test), but not sensitivity (48% vs. 42%, p = 0.621, McNemar's test) of SSEPs for perioperative stroke. A stepwise logistic regression model selected SSEP amplitude loss (p = 0.006, OR = 3.7 [95% CI 1.5-9.2]) and the SSEP change duration (p = 0.034, OR = 1.8 [95% CI 1.1-3.1]) as independent predictors of perioperative stroke. SSEP changes induced by temporary clipping were highly reversible compared to other SSEP changes (94% vs. 60%, p = 0.003, Fisher exact test), and typically responded to clip removal or readjustment. SSEP changes have high specificity and modest sensitivity for perioperative stroke. Stroke risk is a function of both the magnitude of SSEP amplitude loss and the duration of its loss. Given the modest sensitivity, patients may benefit from multimodal monitoring including motor-evoked potentials during cerebral aneurysm surgery.
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Affiliation(s)
- Ahmed I Kashkoush
- Department of Neurological Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Jeffrey Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA
| | - Miguel Habeych
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA
| | - Parthasarathy D Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC, Pittsburgh, PA, USA.
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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13
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Toyooka T, Wada K, Otani N, Tomiyama A, Takeuchi S, Tomura S, Nishida S, Ueno H, Nakao Y, Yamamoto T, Mori K. Potential Risks and Limited Indications of the Supraorbital Keyhole Approach for Clipping Internal Carotid Artery Aneurysms. World Neurosurg X 2019; 2:100025. [PMID: 31218296 PMCID: PMC6580886 DOI: 10.1016/j.wnsx.2019.100025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 02/15/2019] [Indexed: 11/17/2022] Open
Abstract
Background Internal carotid artery (ICA) aneurysm may be a good target for supraorbital keyhole clipping. We discuss the surgical indications and risks of keyhole clipping for ICA aneurysms based on long-term clinical and radiologic results. Methods This was a retrospective analysis of 51 patients (aged 35–75 years, mean 62 years) with ICA aneurysms (mean 5.8 ± 1.8 mm) who underwent clipping via the supraorbital keyhole approach between 2005 and 2017. Neurologic and cognitive functions were examined by several methods, including the modified Rankin Scale and Mini-Mental Status Examination. The state of clipping was assessed 1 year and then every few years after the operation. Results Complete clipping was confirmed in 45 patients (88.2%), dog-ear remnants behind the clip persisted in 4 patients, and wrapping was performed in 2 patients. Mean duration of postoperative hospitalization was 3.4 ± 6.9 days. The mean clinical follow-up period was 6.6 ± 3.2 years. The overall mortality was 0, and overall morbidity (modified Rankin Scale score ≥2 or Mini-Mental Status Examination <24) was 3.9%. Completely clipped aneurysms did not show any recurrence during the mean follow-up period of 6.3 ± 3.1 years, but the 2 (3.9%) aneurysms with neck remnants showed regrowth. Conclusions The risk of neck remnant behind the clip blade is a drawback of supraorbital keyhole clipping. The surgical indication requires preoperative simulation and careful checking of the clip blade state is essential.
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Key Words
- 3D, 3-Dimensional
- AcomA, Anterior communicating artery
- AntChoA, Anterior choroidal artery
- BDI, Beck Depression Inventory
- CT, Computed tomography
- CTA, Computed tomography angiography
- Clipping
- DSA, Digital subtraction angiography
- DWI, Diffusion-weighted imaging
- HAM-D, Hamilton Depression Scale
- HDS-R, Revised Hasegawa Dementia Scale
- ICA, Internal carotid artery
- ISUIA, International Study of Unruptured Intracranial Aneurysms
- Internal carotid artery
- Keyhole surgery
- MCA, Middle cerebral artery
- MMSE, Mini-Mental Status Examination
- MRI, Magnetic resonance imaging
- NIHSS, National Institutes of Health Stroke Scale
- PcomA, Posterior communicating artery
- UCA, Unruptured cerebral aneurysm
- Unruptured cerebral aneurysm
- mRS, Modified Rankin Scale
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Affiliation(s)
- Terushige Toyooka
- Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan.,Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Naoki Otani
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Arata Tomiyama
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Satoshi Tomura
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Sho Nishida
- Department of Neurosurgery, National Defense Medical College, Saitama, Japan
| | - Hideaki Ueno
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Yasuaki Nakao
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Takuji Yamamoto
- Department of Neurosurgery, Juntendo University, Shizuoka Hospital, Shizuoka, Japan
| | - Kentaro Mori
- Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan.,Department of Neurosurgery, National Defense Medical College, Saitama, Japan
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14
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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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15
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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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16
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Symptomatic and silent cerebral infarction following surgical clipping of unruptured intracranial aneurysms: incidence, risk factors, and clinical outcome. Neurosurg Rev 2017; 41:675-682. [PMID: 28983720 DOI: 10.1007/s10143-017-0913-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/21/2017] [Accepted: 09/25/2017] [Indexed: 11/27/2022]
Abstract
Cerebral infarction (CI) associated with clipping of unruptured intracranial aneurysms (UIAs) has not been completely studied. The role of individual and operative characteristics is not known, and the risk of silent CI has not been well described. To determine the incidence, risk factors, and clinical outcome of postoperative CI, we retrospectively analyzed 388 consecutive patients undergoing clipping of UIAs between January 2012 and December 2015. We reviewed the pre- and postoperative computed tomography (CT) images of each patient. Postoperative CI was defined as a new parenchymal hypodensity in the vascular territory of treated artery. Patient-specific, aneurysm-specific, and operative variables were analyzed as potential risk factors. Functional outcome at discharge was assessed with the modified Rankin Scale (mRS). Postoperative CI was found in 49 (12.6%) patients, 29 of whom manifested neurological deficits. The incidences of symptomatic stroke and silent CI were 7.5 and 5.2%, respectively. Multivariate analysis showed that larger aneurysm size and history of hypertension were significantly associated with CI. Disability (mRS > 2) rate was 42.9% among patients with CI, which was substantially higher than that among patients without (0.9%). In conclusion, the incidence of CI following clipping of UIAs was not low. Larger aneurysm size and history of hypertension were independent risk factors. Postoperative symptomatic stroke correlated with an extremely high risk of disability. Silent CI was seemingly nondisabling, but the possible cognitive consequence is pending.
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17
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Perioperative stroke after cerebral aneurysm clipping: Risk factors and postoperative impact. J Clin Neurosci 2017; 44:188-195. [DOI: 10.1016/j.jocn.2017.06.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/15/2017] [Indexed: 11/15/2022]
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18
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Choi HH, Ha EJ, Cho WS, Kang HS, Kim JE. Effectiveness and Limitations of Intraoperative Monitoring with Combined Motor and Somatosensory Evoked Potentials During Surgical Clipping of Unruptured Intracranial Aneurysms. World Neurosurg 2017; 108:738-747. [PMID: 28951267 DOI: 10.1016/j.wneu.2017.09.096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/13/2017] [Accepted: 09/14/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Postoperative neurologic deficits are one of the devastating complications that can result from surgical clipping of unruptured intracranial aneurysms. Intraoperative monitoring (IOM) of motor and somatosensory evoked potentials (EPs) has been used to reduce neurologic sequelae. We evaluated the effectiveness and limitations of IOM in prevention of surgical complications during aneurysm clipping. METHODS A retrospective analysis was performed, involving 386 operations for 429 unruptured intracranial aneurysms in 386 patients with consecutively collected IOM data. RESULTS Significant EP changes were detected during clipping of 23 aneurysms in 23 patients (5.4% of aneurysms). Among them, 8 patients (accounting for 2.1% of operations and 1.9% of aneurysms) experienced postoperative motor deficits, including 3 permanent and 5 temporary motor deficits with corresponding radiologic lesions. In detecting postoperative motor deficits, the sensitivity and specificity of motor EP monitoring were 0.38 and 0.99, respectively, and those of somatosensory EP monitoring were 0.25 and 0.96, respectively. Seven patients (1.8% of operations) with unchanged EPs had other kinds of postoperative neurologic complications, including altered mentality in 5 cases, motor aphasia in 1, and gaze limitation in 1, with corresponding radiologic abnormalities. However, all 7 patients with other neurologic symptoms recovered within 6 months after surgery. CONCLUSIONS IOM of motor and somatosensory EPs was useful and reliable in predicting and preventing postoperative motor deficits. However, it also showed some limitations in the significance of positive EP changes and detection of neurologic deficits other than motor function.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Dongguk University Hospital, Dongguk University College of Medicine, Ilsan, Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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19
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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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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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21
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Grasso G, Landi A, Alafaci C. Multimodal Intraoperative Neuromonitoring in Aneurysm Surgery. World Neurosurg 2017; 101:763-765. [PMID: 28263931 DOI: 10.1016/j.wneu.2017.02.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Giovanni Grasso
- Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences (BIONEC), University of Palermo, Palermo, Italy.
| | - Alessandro Landi
- Department of Neurology and Psychiatry, Neurosurgery, "Sapienza" University of Rome, Rome, Italy
| | - Concetta Alafaci
- Department of Neurosurgery, University of Messina, Messina, Italy
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22
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The incidence of and risk factors for ischemic complications after microsurgical clipping of unruptured middle cerebral artery aneurysms and the efficacy of intraoperative monitoring of somatosensory evoked potentials: A retrospective study. Clin Neurol Neurosurg 2016; 151:128-135. [DOI: 10.1016/j.clineuro.2016.10.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/11/2016] [Accepted: 10/13/2016] [Indexed: 11/16/2022]
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23
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Sakarunchai I, Kato Y, Yamada Y, Inamasu J. Ischemic Event and Risk Factors of Embolic Stroke in Atherosclerotic Cerebral Aneurysm Patients Treated with a New Clipping Technique. J Stroke Cerebrovasc Dis 2015; 24:2497-507. [PMID: 26384767 DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/13/2015] [Accepted: 06/24/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We would like to know the exact rate of ischemic event and the risk factors associated with embolic stroke by treatment of atherosclerotic cerebral aneurysm with a new technique. METHODS This is a retrospective cohort study in patients diagnosed as unruptured atherosclerotic cerebral aneurysm who underwent microsurgical clipping between January 2012 and August 2014. All intraoperative video recordings were reviewed and chosen in patients who were identified as atherosclerotic lesion on the dome, neck, or parent artery of the aneurysm. The demographic, radiographic, operative, and postoperative data were collected. The primary end point was the incidence of cerebral infarction and the neurologic outcomes using the discharge modified Rankin Scale (mRS) score at postoperation time. A statistical analysis of the factors associated with embolic stroke was done by Fisher exact and Wilcoxon rank-sum tests. The individual surgical technique was demonstrated as an illustration for use as a guide. RESULTS Among 103 atherosclerotic cerebral aneurysms, only 3 patients (2.9%) were associated with postoperative cerebral infarction and 1 of them had permanent neurologic deficit. A good mRS score (0-2) was found in 99% of patients and only 1% had a fair mRS score (3-4). A factor associated with ischemic outcome was duration of operation (P = .046). The differences in the atherosclerotic location showed no statistical significance. CONCLUSIONS We found a very low incidence of embolic infarction after clipping of an atherosclerotic cerebral aneurysm with our new technique. Only duration of the operation time was a dependent risk factor for embolic infarction.
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Affiliation(s)
- Ittichai Sakarunchai
- Division of Neurosurgery, Department of Surgery, Prince of Songkla University, Songkhla, Thailand.
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Joji Inamasu
- Department of Neurosurgery, Fujita Health University School of Medicine, Aichi, Japan
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24
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Thompson BG, Brown RD, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, Duckwiler GR, Harris CC, Howard VJ, Johnston SCC, Meyers PM, Molyneux A, Ogilvy CS, Ringer AJ, Torner J. Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2368-400. [PMID: 26089327 DOI: 10.1161/str.0000000000000070] [Citation(s) in RCA: 616] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. METHODS Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.
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25
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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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26
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Treatment outcomes of surgical clipping for unruptured anterior circulation aneurysm—single institute experiences in the era of neurophysiologic monitoring and endovascular treatment. Neurosurg Rev 2015; 38:677-82. [DOI: 10.1007/s10143-015-0642-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 11/24/2014] [Accepted: 01/19/2015] [Indexed: 11/27/2022]
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27
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Silva PA, Cerejo A, Vilarinho A, Dias C, Vaz R. Regional variations in brain oxygenation during temporary clipping in aneurysm surgery. Neurol Res 2013; 34:971-6. [DOI: 10.1179/1743132812y.0000000103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- P A Silva
- Department of NeurosurgeryFaculty of Medicine, Hospitals . João, Porto, Portugal
| | - A Cerejo
- Department of NeurosurgeryFaculty of Medicine, Hospitals . João, Porto, Portugal
| | - A Vilarinho
- Department of NeurosurgeryFaculty of Medicine, Hospitals . João, Porto, Portugal
| | - C Dias
- Department of Intensive CareFaculty of Medicine, HospitalS . João, Porto, Portugal
| | - R Vaz
- Department of NeurosurgeryFaculty of Medicine, Hospitals . João, Porto, Portugal
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Murai Y, Mizunari T, Takagi R, Amano Y, Mizumura S, Komaba Y, Okubo S, Kobayashi S, Teramoto A. Analysis of ischemic cerebral lesions using 3.0-T diffusion-weighted imaging and magnetic resonance angiography after revascularization surgery for ischemic disease. Clin Neurol Neurosurg 2013. [DOI: 10.1016/j.clineuro.2012.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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29
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Facial corticobulbar motor-evoked potential monitoring during the clipping of large and giant aneurysms of the anterior circulation. J Clin Neurosci 2013; 20:873-8. [PMID: 23313523 DOI: 10.1016/j.jocn.2012.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 04/04/2012] [Accepted: 04/14/2012] [Indexed: 11/23/2022]
Abstract
Surgical outcomes for large and giant intracranial aneurysms are suboptimal. Two important reasons for higher complication rates are either occlusion of perforators or parent arteries during aneurysm clipping, or prolonged temporary occlusion of the main arteries. Somatosensory-evoked potential (SSEP) monitoring and transcranial motor-evoked potential (TcMEP) monitoring are standard techniques for monitoring ischemia either during temporary arterial occlusion or after permanent clipping. In our study, facial corticobulbar motor-evoked potential (FCoMEP) monitoring was included to determine whether this modality improved intraoperative monitoring. FCoMEP were recorded intraoperatively in 21 patients undergoing surgical clipping of large and giant aneurysms of the anterior circulation. Valid TcMEP parameters were obtained for all patients. A correlation tending to significance between a prolonged temporary clipping time and TcMEP decrement was observed. In addition to this, the inclusion of FCoMEP improved the sensitivity of extremity muscle motor-evoked potential (ExMEP, which included TcMEP) monitoring (from 80% to 100%). In the long-term assessment, a favorable outcome was achieved in 16 of the 21 patients (76%). In conclusion, FCoMEP provides complementary corticobulbar tract information for detecting perforating vessel compromise that may lead to motor impairment and that is not identified by ExMEP.
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Interdisciplinary treatment of unruptured intracranial aneurysms: impact of intraprocedural rupture and ischemia in 563 aneurysms. J Neurol 2012; 260:1304-13. [DOI: 10.1007/s00415-012-6795-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 11/07/2012] [Accepted: 12/08/2012] [Indexed: 11/25/2022]
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31
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Chong CT, Manninen PH. Anesthesia for cerebral revascularization for adult moyamoya syndrome associated with sickle cell disease. J Clin Neurosci 2011; 18:1709-12. [DOI: 10.1016/j.jocn.2011.03.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 03/22/2011] [Indexed: 11/16/2022]
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32
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Cerejo A, Silva PA, Dias C, Vaz R. Monitoring of brain oxygenation in surgery of ruptured middle cerebral artery aneurysms. Surg Neurol Int 2011; 2:70. [PMID: 21697985 PMCID: PMC3115273 DOI: 10.4103/2152-7806.81732] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 05/07/2011] [Indexed: 11/09/2022] Open
Abstract
Background: The occurrence of brain ischemic lesions, due to temporary arterial occlusion or incorrect placement of the definitive clip, is a major complication of aneurysm surgery. Temporary clipping is a current technique during surgery and there is no reliable method of predicting the possibility of ischemia due to extended regional circulatory interruption. Even with careful inspection, misplacement of the definitive clip can be difficult to detect. Brain tissue oxygen concentration (PtiO2) was monitored during surgery of middle cerebral artery (MCA) aneurysm presenting with subarachnoid hemorrhage (SAH), for detection of changes in brain oxygenation due to reduced blood flow, as a predictor of ischemic events, during temporary clipping and after definitive clipping. Methods: PtiO2 was monitored during surgery of 13 patients harboring MCA aneurysms presenting with SAH, using a polarographic microcatheter (Licox, GMS, Kiel, Germany) placed in the territory of MCA. Results A decrease in PtiO2 values was verified in every period of temporary clipping. Brain infarction occurred in 2 patients; in both cases, there was a decrease in PtiO2 greater than 80% from basal value, a minimum value of less than 2 mmHg persisting for 2 or more minutes during temporary clipping, and an incomplete recovery of PtiO2 after definitive clipping. In 2 patients, incomplete recovery of values after definitive clipping led to verification of inappropriate placement and repositioning of the clip. Conclusion: The results suggest that intraoperative monitoring of PtiO2 may be a useful method of detection of changes in brain tissue oxygenation during MCA aneurysm surgery. Postoperative infarction in the territory of MCA developed in cases with an abrupt decrease of PtiO2 and a very low and persistent minimum value, during temporary clipping, and an incomplete recovery after definitive clipping. Verification of clip position should be considered when there is an incomplete recovery or a persistent fall in PtiO2 after definitive clipping.
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Affiliation(s)
- António Cerejo
- Department of Neurosurgery, Hospital S. João, Porto, Portugal
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Role of calcification in the outcomes of treated, unruptured, intracerebral aneurysms. Acta Neurochir (Wien) 2011; 153:905-11. [PMID: 21286763 DOI: 10.1007/s00701-010-0846-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE This study examined clinical and aneurysm characteristics in patients with unruptured aneurysms, treated with either coiling or clipping at a single institution, with the primary outcome-Glasgow Outcome Score (GOS)-measured at 6 months after treatment. METHODS Data was obtained by a retrospective review of a prospective registry of consecutive cases of unruptured intracranial aneurysms treated at a single institution from 2002 to mid 2007. Demographic data, number, location, and size of aneurysms, calcification, mode of treatment, ASA score, presence of a stroke on post-op imaging, and GOS were recorded. Medical 9.4 for PC was utilized for statistical analysis. RESULTS There were 225 procedures performed in 208 patients to treat 252 aneurysms. The mean age was 54.6 years, 74.5% were female, the mean ASA score was 2.45, and 72.2% were smokers. Mean aneurysm size was 8.6 mm. A total of 157 (70%) craniotomies and 68 (30%) coiling procedures were performed. Coiling was utilized more frequently in the posterior circulation [18/32 (56%) posterior circulation, 50/193 (29.9%) anterior circulation, p < 0.001 Chi-square]. Length of hospital stay averaged 5.3 days [6.2 vs. 3.2 clip/coil, p < 0.001, Mann-Whitney]. Overall favorable outcome of GOS 4-5 measured at 6 months post-procedure was 93.3% [145/157 (92.3%) clip, 66/68 (97%) coil, p = 0.3 Chi-square], with a single mortality in the coil group. There was radiographic evidence of a post-procedure stroke on CT in 31 (13.8%) [28/157 (17.8%) clip, 3/68 (4.4%) coil, p < 0.001, Chi-square], but only 11(35%) were symptomatic. All long-term morbidity was attributable to stroke except for one case of late hydrocephalus. Utilizing a logistic regression multivariate analysis (forward), none of the examined factors (age, ASA score, sex, surgeon, posterior circulation, number of aneurysms treated at one sitting, size of aneurysm, smoking status, or type of therapy) related to outcome except calcified aneurysm [20/25 (80%) calcified, 191/200 (95.5%) non-calcified, p < 0.01 Chi-square] with an OR = 7.8 (2.2-28.4, 95% C.I.). Although a univariate analysis of aneurysm size versus outcome achieves statistical significance [p = 0.05, logistic regression (forced)], when the calcified cases are removed from consideration, it does not [p = 0.55, OR = .95, (.82-1.1), 95% C.I.]. Excluding patients with calcified aneurysms resulted in the following calculation of favorable outcome: 94.2% (130/138) clip and 98.4% (61/62) coil [p = 0.33, Chi-square]. CONCLUSIONS In this study, the presence of calcification in an aneurysm was the sole marker of adverse outcome. Larger aneurysms tended to be more likely to be calcified. Size by itself did not have an adverse affect on outcome. Clipping or clip reconstruction of calcified aneurysms is a significant source of morbidity in the treatment of unruptured aneurysms (Odds ratio 7.8).
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Cerejo A, Silva PA, Dias C, Vaz R. Monitoring of brain tissue oxygenation in surgery of middle cerebral artery incidental aneurysms. Surg Neurol Int 2011; 2:37. [PMID: 21541203 PMCID: PMC3086171 DOI: 10.4103/2152-7806.78250] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 02/25/2011] [Indexed: 11/16/2022] Open
Abstract
Introduction: The management of incidental unruptured aneurysms remains a matter of controversy; middle-sized or large anterior circulation incidental aneurysms, in young or middle age patients, should be considered for treatment. Surgical clipping is an accepted treatment for middle cerebral artery unruptured aneurysms. Ischemic events can occur even in cases of incidental aneurysm surgery. Since regional cerebral blood flow can be compromised due to temporary arterial clipping or to incorrect placement of defi nitive clip, we performed intra-operative monitoring of brain tissue oxygen concentration (PtiO2), to detect changes in brain oxygenation due to reduced blood fl ow, eventually leading to ischemia, during surgery of middle cerebral artery incidental aneurysms. Methods: PtiO2 monitoring was performed during surgery of eight patients harboring incidental MCA aneurysms, using a polarographic microcatheter (Licox, GMS – Kiel, Germany), placed in the temporal lobe on the side of the lesion, from dural opening to dural closure. Results: Basal values varied between 2.3 and 27.3 mmHg; these values are lower than those previously described in the literature as “normal” for uninjured brain or in cases of subarachnoid hemorrhage. In all patients, a significant decrease in PtiO2 was found in every period of temporary clipping of MCA. Post-operative infarction in the territory of middle cerebral artery occurred in one patient and, in that case, there was a persistent minimum value of 0.6 mmHg, without recovery after the placement of the definitive clip. In another patient, an incorrect placement of the definitive clip could be predicted by a decrease in PtiO2 value. Conclusions: PtiO2 monitoring during aneurysm surgery shows brain tissue perfusion in real time and there is a correlation between any episode of reduced blood flow to the affected vascular territory during surgery and a decrease of PtiO2 values. Unexpected low basal values were obtained in “uninjured” brain, with no influence from subarachnoid hemorrhage. The values of risk for brain infarction during temporary arterial occlusion still need further studies, but an incomplete recovery or a persistent fall in PtiO2 values after definitive clipping should be considered as an indication for verification of the position of the clip.
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Affiliation(s)
- A Cerejo
- Department of Neurosurgery, Hospital S. João, Porto, Portugal
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Krayenbühl N, Oinas M, Erdem E, Krisht AF. The Impact of Minimizing Brain Retraction in Aneurysm Surgery: Evaluation Using Magnetic Resonance Imaging. Neurosurgery 2011; 69:344-8. [DOI: 10.1227/neu.0b013e31821819a0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Recent advances in skull base and microsurgical techniques minimize the need for brain retraction.
OBJECTIVE:
We studied the impact of such techniques in 36 patients (51 aneurysms) using magnetic resonance imaging (MRI).
METHODS:
Preoperative and 24 hours postoperative MR imaging was performed in patients undergoing microsurgical clipping of intracranial aneurysms. Images were evaluated for parenchymal signal changes. During surgery, use and time of brain retraction were recorded. The degree of cortical injury was quantified using a 0 to 3 scale (grade 0 = normal surface; 1 = pial/arachnoidal damage; 2 = gray matter injury; 3 = contusion/necrosis).
RESULTS:
Brain retraction by use of a brain spatula was used in all patients. Retraction times ranged from 14 to 290 minutes (mean, 84.1). Cortical surface changes were grade 0 in 86% and grade 1 in 14%; none showed grade 2 or 3 changes. In the postoperative MRI, 4 patients presented with parenchymal alterations, 4 with edema (11.1%), and 1 patient had additional contusion (2.8%). All lesions were confined to the temporal pole. The grade of cortical surface changes was not related to lesions found on MR imaging. No patients showed retraction-related neurological deficits.
CONCLUSION:
The incidence of evident mechanical parenchymal injury (infarction or contusion) is very low when appropriate microsurgical and skull base techniques are used. Minor pia-arachnoid injury should nevertheless continue to be attended through future advances.
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Affiliation(s)
- Niklaus Krayenbühl
- Department of Neurosurgery, University Hospital Zürich, Zürich, Switzerland
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Minna Oinas
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Eren Erdem
- Department of Neuroradiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ali F. Krisht
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Arkansas Neuroscience Institute, Little Rock, Arkansas
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Krayenbühl N, Sarnthein J, Oinas M, Erdem E, Krisht AF. MRI-validation of SEP monitoring for ischemic events during microsurgical clipping of intracranial aneurysms. Clin Neurophysiol 2011; 122:1878-82. [PMID: 21377924 DOI: 10.1016/j.clinph.2011.02.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 12/20/2010] [Accepted: 02/08/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE During surgical clipping of intracranial aneurysms, reduction in SEP amplitude is thought to indicate cortical ischemia and subsequent neurological deficits. Since the sensitivity of SEP is questioned, we investigated SEP with respect to post-operative ischemia. METHODS In 36 patients with 51 intracranial aneurysms, clinical evaluation and diffusion-weighted MRI (DWI) was performed before and within 24h after surgery. During surgery, time of temporary occlusion was recorded. MRI images were reviewed for signs of ischemia. RESULTS For 43 clip applications (84%), we observed neither pathologic SEP events nor ischemia in MRI. In two cases where reduction lasted >10 min after clip release, SEP events correlated with ischemia in the MRI. Only one of the ischemic patients was symptomatic and developed a transient hemiparesis. CONCLUSIONS While pathologic SEP events correlated with visible ischemia in MRI only in two cases with late SEP recovery, ischemia in MRI may have been transient or may not have reached detection threshold in the other cases, in agreement with the absence of permanent neurological deficits. SIGNIFICANCE In complex aneurysm cases, where prolonged temporary occlusion is expected, SEP should be used to detect ischemia at a reversible stage to improve the safety of aneurysm clipping.
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Affiliation(s)
- Niklaus Krayenbühl
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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Hepatic encephalopathy with reversible focal neurologic signs resembling acute stroke: case report. J Stroke Cerebrovasc Dis 2010; 20:377-80. [PMID: 20634097 DOI: 10.1016/j.jstrokecerebrovasdis.2010.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 12/23/2009] [Accepted: 01/05/2010] [Indexed: 01/08/2023] Open
Abstract
A 64-year-old female with a history of primary biliary cirrhosis and esophageal varices starting at age 39 was brought to our Stroke Care Unit by ambulance with right-side weakness and speech difficulty. Physical examination revealed right hemiparesis (including the face), sensory disturbances, pathological reflexes, and slightly decreased consciousness, with a Glasgow Coma Scale rating of E3V4M6. Flapping tremors and speech disturbance, as well as anarithmia, construction apraxia, and ideomotor apraxia, were noted, and her National Institutes of Health Stroke Scale score was 13. Initially, the patient was diagnosed with acute stroke and treated accordingly; however, subsequent findings from clinical images and electroencephalography led to a diagnosis of focal neurologic signs due to hepatic encephalopathy (HE). The patient had significantly reduced cerebral blood flow in the left side of the brain, probably due to microsurgical repair of an aneurysm done 2 years earlier. HE with exaggerated chronic liver damage might have made the previously silent ischemia clinically apparent. This interpretation is supported by the fact that the patient's neurologic deficits resolved once HE was adequately controlled. This case illustrates the need for careful assessment of background pathophysiology when diagnosing patients with stroke-like symptoms.
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Alshekhlee A, Mehta S, Edgell RC, Vora N, Feen E, Mohammadi A, Kale SP, Cruz-Flores S. Hospital mortality and complications of electively clipped or coiled unruptured intracranial aneurysm. Stroke 2010; 41:1471-6. [PMID: 20522817 DOI: 10.1161/strokeaha.110.580647] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To determine the hospital mortality rates associated with elective surgical clipping and endovascular coiling of unruptured intracranial aneurysms. METHODS We identified a cohort of patients electively admitted to US hospitals with the diagnosis of unruptured intracranial aneurysm from the National Inpatient Sample database for the years 2000 through 2006. Patient demographics, hospital-associated complications, and in-hospital mortality were compared among the treatment groups. A multivariate logistic regression analysis was used to identify independent variables associated with hospital mortality. Cochrane-Armitage test was used to assess the trend of hospital use of these procedures. RESULTS After data cleansing, 3738 (34.3%) patients had aneurysm clipping and 3498 (32.1%) had endovascular coiling. The basic demographics including age, race, and comorbidity indices were similar between the groups. The length of hospital stay was longer in the clipped population (median 4 versus 1 day; P<0.0001), incurring a higher hospital charge in the coiled population (median $42 070 versus $38 166; P<0.0001). Hospital mortality was higher in the clipped population: 60 (1.6%) versus 20 (0.57%; adjusted odds ratio 3.63; 95% CI, 1.57, 8.42). Perioperative intracerebral hemorrhage and acute ischemic stroke were higher in the clipped population. The rate of hospital use of the endovascular coiling has increased over the years included in this study (<0.0001). CONCLUSIONS Elective coiling of unruptured intracranial aneurysms is associated with fewer deaths and perioperative complications compared with elective clipping. The trend of hospital use of the coiling procedures has increased during recent years.
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Affiliation(s)
- Amer Alshekhlee
- Department of Neurology, St. Louis University, St. Louis, MO 63104, USA.
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Transcranial motor evoked potential monitoring during the surgical clipping of unruptured intracranial aneurysms. J Neurol Sci 2010; 293:29-34. [DOI: 10.1016/j.jns.2010.03.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 02/28/2010] [Accepted: 03/18/2010] [Indexed: 11/24/2022]
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van Doormaal TPC, van der Zwan A, Verweij BH, Regli L, Tulleken CAF. Giant Aneurysm Clipping Under Protection of an Excimer Laser–Assisted Non-occlusive Anastomosis Bypass. Neurosurgery 2010; 66:439-47; discussion 447. [DOI: 10.1227/01.neu.0000364998.95710.73] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
OBJECTIVE
To define the safety and clinical value of giant aneurysm clipping under protection of an excimer laser–assisted non-occlusive anastomosis (ELANA) bypass.
METHODS
We report 32 patients with an uncoilable intracerebral giant aneurysm, operated on with the aid of an ELANA protective bypass between January 1, 1994, and January 1, 2008. We retrospectively collected data from patient records. Follow-up data were updated by telephone interview. We defined a favorable outcome as a successfully treated aneurysm and a better or equal postoperative modified Rankin scale (mRS) score compared with the preoperative mRS.
RESULTS
In total 33 bypasses were constructed, of which 31 (94%) were patent during the rest of the procedure. The first failed bypass was salvaged during a second procedure. Of the second failed bypass, the ELANA anastomosis could be reused during second bypass surgery. All 32 aneurysms could be treated. The bypasses served as protection during temporary parent vessel occlusion (n = 24, 75%), control during aneurysm rupture (n = 3, 9%), and in all patients as an indicator for recipient artery narrowing during clip placement. Four bypasses (12%) eventually had to partially (n = 3) or fully (n = 1) replace recipient artery flow at the end of surgery. Postoperatively, 3 patients (9%) had a hemorrhagic complication and 2 patients (6%) had an ischemic complication. At long-term follow-up (mean, 6.1 ± 3.4 y), 28 patients (88%) had a favorable functional outcome.
CONCLUSION
The ELANA protective bypass is a safe and useful instrument for the treatment of these difficult aneurysms.
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Affiliation(s)
- Tristan P. C. van Doormaal
- Rudolf Magnus Institute of Neuroscience, Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Albert van der Zwan
- Rudolf Magnus Institute of Neuroscience, Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bon H. Verweij
- Rudolf Magnus Institute of Neuroscience, Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luca Regli
- Rudolf Magnus Institute of Neuroscience, Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Krayenbühl N, Krisht AF. Response to Letter by Juvela et al. Stroke 2009. [DOI: 10.1161/strokeaha.109.557108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Niklaus Krayenbühl
- Department of Neurosurgery, University Hospital Zürich, Zürich, Switzerland
| | - Ali F. Krisht
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Ark
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Juvela S, Siironen J. Cerebral ischemia after aneurysmal subarachnoid hemorrhage. Stroke 2009; 40:e547; author reply e548. [PMID: 19443792 DOI: 10.1161/strokeaha.109.550103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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