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Spetzger U. Enhance Safety in Aneurysm Surgery: Strategies for Prevention of Intraoperative Vascular Complications. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:53-64. [PMID: 37548724 DOI: 10.1007/978-3-030-12887-6_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Complications during surgery for intracranial aneurysms can be devastating. Notorious pitfalls include premature rupture, parent vessel occlusion, local cerebral injury and brain contusion, and incomplete neck obliteration. These unfavorable intraoperative events can result in major neurological deficits with permanent morbidity and even mortality. Herein, the author highlights the relevant surgical strategies used in his daily practice of aneurysm surgery (e.g., aneurysm clipping with adenosine-induced temporary cardiac arrest), application of which may help prevent vascular complications and enhance surgical safety through reduction of the associated risks, thus allowing improvement of postoperative outcomes. Overall, all described methods and techniques should be considered as small pieces in the complex puzzle of prevention of vascular complications during aneurysm surgery.
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Affiliation(s)
- Uwe Spetzger
- Department of Neurosurgery, Klinikum Karlsruhe, Karlsruhe, Germany.
- Faculty of Computer Science, Institute for Anthropomatics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany.
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Dugani SM. Management of Intraoperative Rupture of Intracranial Aneurysms: Agony and Ecstasy. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:65-79. [PMID: 37548725 DOI: 10.1007/978-3-030-12887-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Intraoperative rupture (IOR) of an intracranial aneurysm is a serious complication, often with catastrophic consequences that are difficult to manage even by the best hands. Like most surgical complications, this one is better to avoid than to treat, but any vascular neurosurgeon should know how to deal with IOR of an aneurysm, because it is bound to occur. The aims of this study were to evaluate the incidence and factors associated with IOR during clipping of intracranial aneurysms, to analyze strategies for controlling hemorrhage in such cases, and to assess outcomes. Overall, 911 cases of intracranial aneurysms, which were treated surgically by the author during 26 years of his professional career, were reviewed. IOR was never noted during clipping of an unruptured intracranial aneurysm (65 cases) but was encountered in 49 of 846 cases (5.8%) presenting with subarachnoid hemorrhage. This complication occurred most often in cases of internal carotid artery aneurysms (22 cases; 45%), followed by anterior communicating artery aneurysms (12 cases; 24%), distal anterior cerebral artery aneurysms (6 cases; 12%), middle cerebral artery aneurysms (6 cases; 12%), and posterior circulation aneurysms (3 cases; 6%). IOR was mostly encountered during early surgery (within 3 days) after the ictus (26 cases; 53%) and most frequently occurred during dissection of the aneurysm (26 cases; 53%). Overall, 22 patients (45%) had good outcome, 18 (37%) had variable morbidity, and 9 (18%) died. Fatal consequences of IOR were noted only in cases of big or multilobulated internal carotid artery aneurysms. Detailed planning of the surgical procedure, application of meticulous microdissection techniques, and anticipation of possible intraoperative incidents during intervention aimed at clipping of an intracranial aneurysm can reduce the risk of IOR, as well as the associated morbidity and mortality.
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Affiliation(s)
- Suresh M Dugani
- Department of Neurosurgery, SDM College of Medical Sciences & Hospital, Dharwad-Hubballi, Karnataka, India.
- Regional Neuroscience Centre, Shivakrupa Hospital, Dharwad-Hubballi, Karnataka, India.
- Suchirayu Hospital, Dharwad-Hubballi, Karnataka, India.
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Radhakrishna N, Khandelwal A, Chouhan RS, Pandia MP, Burman S, Mahapatra RR. Complications and Neurological Outcome following Intraoperative Aneurysm Rupture in Adult Patients Undergoing Intracranial Aneurysmal Clipping: A Retrospective Study. J Neurosci Rural Pract 2021; 12:382-388. [PMID: 33927528 PMCID: PMC8064845 DOI: 10.1055/s-0041-1724228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background Intraoperative aneurysmal rupture (IAR) is a catastrophic complication; however, its impact on neurological outcome is debatable. We studied the effects of IAR on intraoperative and postoperative complications and neurological outcome. Methods In this retrospective study, adult patients who underwent aneurysmal clipping over a period of 2 years were divided as follows: group R (with IAR) and group N (without IAR). Various perioperative parameters, intraoperative and postoperative complications were noted. Glasgow outcome scale (GOS) was noted at discharge from hospital and categorized as favorable (GOS IV and V) and unfavorable (GOS I, II and III). Collected data was statistically analyzed. Univariate and multiple logistic regression analyses were performed to identify predictors of IAR. A p value < 0.05 was considered significant. Results Thirty-two out of 195 (16.41%) patients suffered IAR, with majority involving anterior communicating artery aneurysm (46.88%). Duration of temporary clipping ( p < 0.001), volume of blood loss, and fluid and blood transfusion were significantly more in group R. Postoperatively, significantly more patients in group R developed intracranial hematoma, cerebral infarct, and required prolonged ventilatory support (≥5 days). Unfavorable neurological outcome was observed more in group R ( p = 0.013). In univariate analysis, blood loss > 500 mL, use of colloids, and duration of surgery > 5 hours were found to be associated with IAR. After multiple logistic regression analysis, only use of colloids and duration of surgery > 5 hours were the most predictive variables for IAR. Conclusions IAR is associated with serious intraoperative and postoperative complications and unfavorable neurological outcome.
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Affiliation(s)
- Nayani Radhakrishna
- Department of Anaesthesia and Critical Care, Army Hospital Research and Referral, Delhi Cantt, India
| | - Ankur Khandelwal
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajendra Singh Chouhan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Mihir Prakash Pandia
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sourav Burman
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rashmi Rani Mahapatra
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Muirhead WR, Grover PJ, Toma AK, Stoyanov D, Marcus HJ, Murphy M. Adverse intraoperative events during surgical repair of ruptured cerebral aneurysms: a systematic review. Neurosurg Rev 2020; 44:1273-1285. [PMID: 32542428 PMCID: PMC8121724 DOI: 10.1007/s10143-020-01312-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/17/2020] [Accepted: 04/29/2020] [Indexed: 11/28/2022]
Abstract
Compared with endovascular techniques, clipping of ruptured cerebral aneurysms has been shown to associate with increased morbidity in several studies. Despite this, clipping remains the preferred option for many aneurysms. The objective of this study is to describe the reported adverse events of open repair of ruptured cerebral aneurysms and their impact on patient outcome. The PubMed, Embase and Cochrane databases were searched between June 1999 and June 2019 to identify original studies of at least 100 patients undergoing surgical repair of ruptured cerebral aneurysms and in which adverse event rates were reported. Thirty-six studies reporting adverse events in a total of 12,410 operations for repair of ruptured cerebral aneurysms were included. Surgical adverse events were common with 36 event types reported including intraoperative rupture (median rate of 16.6%), arterial injury (median rate of 3.8%) and brain swelling (median rate 5.6%). Only 6 surgical events were statistically shown to associate with poor outcomes by any author and for intraoperative rupture (the most frequently analysed), there was an even split between authors finding a statistical association with poor outcome and those finding no association. Even with modern surgical techniques, the technical demands of surgical aneurysm repair continue to lead to a high rate of intraoperative adverse events. Despite this, it is not known which of these intraoperative events are the most important contributors to the poor outcomes often seen in these patients. More research directed towards identifying the events that most drive operative morbidity has the potential to improve outcomes for these patients.
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Affiliation(s)
- William R Muirhead
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
| | - Patrick J Grover
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ahmed K Toma
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Danail Stoyanov
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Hani J Marcus
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.,Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
| | - Mary Murphy
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
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de Oliveira Manoel AL, van der Jagt M, Amin-Hanjani S, Bambakidis NC, Brophy GM, Bulsara K, Claassen J, Connolly ES, Hoffer SA, Hoh BL, Holloway RG, Kelly AG, Mayer SA, Nakaji P, Rabinstein AA, Vajkoczy P, Vergouwen MDI, Woo H, Zipfel GJ, Suarez JI. Common Data Elements for Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Working Group on Hospital Course and Acute Therapies-Proposal of a Multidisciplinary Research Group. Neurocrit Care 2020; 30:36-45. [PMID: 31119687 DOI: 10.1007/s12028-019-00726-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The Common Data Elements (CDEs) initiative is a National Institute of Health/National Institute of Neurological Disorders and Stroke (NINDS) effort to standardize naming, definitions, data coding, and data collection for observational studies and clinical trials in major neurological disorders. A working group of experts was established to provide recommendations for Unruptured Aneurysms and Aneurysmal Subarachnoid Hemorrhage (SAH) CDEs. METHODS This paper summarizes the recommendations of the Hospital Course and Acute Therapies after SAH working group. Consensus recommendations were developed by assessment of previously published CDEs for traumatic brain injury, stroke, and epilepsy. Unruptured aneurysm- and SAH-specific CDEs were also developed. CDEs were categorized into "core", "supplemental-highly recommended", "supplemental" and "exploratory". RESULTS We identified and developed CDEs for Hospital Course and Acute Therapies after SAH, which included: surgical and procedure interventions; rescue therapy for delayed cerebral ischemia (DCI); neurological complications (i.e. DCI; hydrocephalus; rebleeding; seizures); intensive care unit therapies; prior and concomitant medications; electroencephalography; invasive brain monitoring; medical complications (cardiac dysfunction; pulmonary edema); palliative comfort care and end of life issues; discharge status. The CDEs can be found at the NINDS Web site that provides standardized naming, and definitions for each element, and also case report form templates, based on the CDEs. CONCLUSION Most of the recommended Hospital Course and Acute Therapies CDEs have been newly developed. Adherence to these recommendations should facilitate data collection and data sharing in SAH research, which could improve the comparison of results across observational studies, clinical trials, and meta-analyses of individual patient data.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- Neuroscience Research Program in the Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Canada. .,Adult Critical Care Unit, Department of Critical Care Medicine, Hospital Paulistano - UnitedHealth Group Brazil, Rua Martiniano de Carvalho, 741, Bela Vista, São Paulo, SP, 01321-001, Brazil.
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Nicholas C Bambakidis
- Department of Neurological Surgery, UH Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Richmond, VA, USA
| | - Ketan Bulsara
- Department of Neurosurgery, University of Connecticut, Farmington, CT, USA
| | | | | | - S Alan Hoffer
- Department of Neurological Surgery, UH Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Adam G Kelly
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Peter Vajkoczy
- Department of Neurosurgery, Charite Hospital, Universitatsmedizin, Berlin, Germany
| | - Mervyn D I Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Henry Woo
- Department of Neurosurgery and Radiology, Zucker School of Medicine at Hofstra/Northwell Health, New York, NY, USA
| | | | - Jose I Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
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Malinova V, Schatlo B, Voit M, Suntheim P, Rohde V, Mielke D. The impact of temporary clipping during aneurysm surgery on the incidence of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 2018; 129:84-90. [PMID: 28946178 DOI: 10.3171/2017.3.jns162505] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clipping of a ruptured intracranial aneurysm requires some degree of vessel manipulation, which in turn is believed to contribute to vasoconstriction. One of the techniques used during surgery is temporary clipping of the parent vessel. Temporary clipping may either be mandatory in cases of premature rupture (rescue) or represent a precautionary or facilitating surgical step (elective). The aim of this study was to study the association between temporary clipping during aneurysm surgery and the incidence of vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) in a large clinical series. METHODS Seven hundred seventy-eight patients who underwent surgical aneurysm treatment after aSAH were retrospectively included in the study. In addition to surgical parameters, the authors recorded transcranial Doppler (TCD) sonography-documented vasospasm (TCD-vasospasm, blood flow acceleration > 120 cm/sec), delayed ischemic neurological deficits (DINDs), and delayed cerebral infarction (DCI). Multivariate binary logistic regression analysis was applied to assess the association between temporary clipping, vasospasm, DIND, and DCI. RESULTS Temporary clipping was performed in 338 (43.4%) of 778 patients during aneurysm surgery. TCD sonographic flow acceleration developed in 370 (47.6%), DINDs in 123 (15.8%), and DCI in 97 (12.5%). Patients with temporary clipping showed no significant increase in the incidence of TCD-vasospasm compared with patients without temporary clipping (49% vs 48%, respectively; p = 0.60). DINDs developed in 12% of patients with temporary clipping and 18% of those without temporary clipping (p = 0.01). DCI occurred in 9% of patients with temporary clipping and 15% of those without temporary clipping (p = 0.02). The need for rescue temporary clipping was a predictor for DCI; 19.5% of patients in the rescue temporary clipping group but only 11.3% in the elective temporary clipping group had infarcts (p = 0.02). Elective temporary clipping was not associated with TCD-vasospasm (p = 0.31), DIND (p = 0.18), or DCI (p = 0.06). CONCLUSIONS Temporary clipping did not contribute to a higher rate of TCD-vasospasm, DIND, or DCI in comparison with rates in patients without temporary clipping. In contrast, there was an association between temporary clipping and a lower incidence of DINDs and DCI. There is no reason to be hesitant in using elective temporary clipping if deemed appropriate.
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Affiliation(s)
- Vesna Malinova
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | - Bawarjan Schatlo
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | - Martin Voit
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
| | | | - Veit Rohde
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
- 2Department of Neurosurgery, RWTH University, Aachen, Germany
| | - Dorothee Mielke
- 1Department of Neurosurgery, Georg-August-University Göttingen; and
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Abstract
PURPOSE OF REVIEW With recent research trying to explore the pathophysiologic mechanisms behind vasospasm, newer pharmacological and nonpharmacological treatments are being targeted at various pathways involved. This review is aimed at understanding the mechanisms and current and future therapies available to treat vasospasm. RECENT FINDINGS Computed tomography perfusion is a useful alternative tool to digital subtraction angiography to diagnose vasospasm. Various biomarkers have been tried to predict the onset of vasospasm but none seems to be helpful. Transcranial Doppler still remains a useful tool at the bedside to screen and follow up patients with vasospasm. Hypertension rather than hypervolemia and hemodilution in 'Triple-H' therapy has been found to be helpful in reversing the vasospasm. Hyperdynamic therapy in addition to hypertension has shown promising effects. Endovascular approaches with balloon angioplasty and intra-arterial nimodipine, nicardipine, and milrinone have shown consistent benefits. Endothelin receptor antagonists though relieved vasospasm, did not show any benefit on functional outcome. SUMMARY Endovascular therapy has shown consistent benefit in relieving vasospasm. An aggressive combination therapy through various routes seems to be the most useful approach to reduce the complications of vasospasm.
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Zhang H, He X, Wang Y, Sun X, Zhu L, Lei C, Yin J, Li X, Hou F, He W, Zhao D. Neuritin attenuates early brain injury in rats after experimental subarachnoid hemorrhage. Int J Neurosci 2017; 127:1087-1095. [PMID: 28562156 DOI: 10.1080/00207454.2017.1337013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Hang Zhang
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Xuejun He
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Yezhong Wang
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Xiaokun Sun
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Licang Zhu
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Chao Lei
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Jiangwen Yin
- Department of Anesthesiology, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Xiaotian Li
- Department of Neurosurgery, Weifang People's HospitalWeifang, Shandong, China
| | - Fandi Hou
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Wengao He
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
| | - Dong Zhao
- Department of Neurosurgery, First Affiliated Hospital of Medical College, Shihezi University, Xinjiang, China
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Intraoperative rupture in the surgical treatment of patients with intracranial aneurysms. J Clin Neurosci 2016; 34:63-69. [PMID: 27692502 DOI: 10.1016/j.jocn.2016.01.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 01/26/2016] [Indexed: 11/23/2022]
Abstract
Intraoperative rerupture (IOR) during clipping of cerebral aneurysms is a difficult complication of microneurosurgery. The aim of this study was to evaluate the incidence of IOR and analyze the strategies for controlling profound hemorrhage. A total of 165 patients with unruptured intracranial aneurysms and 46 patients with subarachnoid hemorrhage (SAH) treated surgically between April 2010 and March 2011, were reviewed. The data were collected with regard to age, sex, presence of symptoms, confounding factors and strategy for controlling intraoperative hemorrhage was analyzed in terms of location of aneurysms, timing of rupture and severity of IOR. 211 patients with 228 aneurysms were treated in this series. There were a total of six IORs which represented an IOR rate of 2.84% per patient and 2.63% per aneurysm. The highest ruptures rates occurred in patients with internal carotid artery aneurysms (25%). Surgeries in the group with ruptured aneurysms had a much higher rate of IOR compared with surgeries in the group with unruptured aneurysms. Of the six IOR aneurysms, one occurred during predissection, four during microdissection and one during clipping. One was major IOR, three were moderate and two were minor. Intraoperative rupture of an intracranial aneurysm can be potentially devastating in vascular neurosurgery. Aneurysm location, presence of SAH and surgical experience of the operating surgeon seem to be important factors affecting the incidence of IOR.
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Abstract
AbstractCerebral vasospasm is a prolonged but reversible narrowing of cerebral arteries beginning days after subarachnoid hemorrhage. Progression to cerebral ischemia is tied mostly to vasospasm severity, and its pathogenesis lies in artery encasement by blood clot, although the complex interactions between hematoma and surrounding structures are not fully understood. The delayed onset of vasospasm provides a potential opportunity for its prevention. It is disappointing that recent randomized, controlled trials did not demonstrate that the endothelin antagonist clazosentan, the cholesterol-lowering agent simvastatin, and the vasodilator magnesium sulfate improve patient outcome. Minimizing ischemia by avoiding inadequate blood volume and pressure, administering the calcium antagonist nimodipine, and intervention with balloon angioplasty, when necessary, constitutes current best management. Over the past two decades, our ability to manage vasospasm has led to a significant decline in patient morbidity and mortality from vasospasm, yet it still remains an important determinant of outcome after aneurysm rupture.
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Torné R, Rodríguez-Hernández A, Lawton MT. Intraoperative arteriovenous malformation rupture: causes, management techniques, outcomes, and the effect of neurosurgeon experience. Neurosurg Focus 2015; 37:E12. [PMID: 25175431 DOI: 10.3171/2014.6.focus14218] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraoperative rupture can transform an arteriovenous malformation (AVM) resection. Blood suffuses the field and visualization is lost; suction must clear the field and the hand holding the suction device is immobilized; the resection stalls while hemostasis is being reestablished; the cause and site of the bleeding may be unclear; bleeding may force technical errors and morbidity from chasing the source into eloquent white matter; and AVM bleeding can be so brisk that it overwhelms the neurosurgeon. The authors reviewed their experience with this dangerous complication to examine its causes, management, and outcomes. METHODS From a cohort of 591 patients with AVMs treated surgically during a 15-year period, 32 patients (5%) experienced intraoperative AVM rupture. Their prospective data and medical records were reviewed. RESULTS Intraoperative AVM rupture was not correlated with presenting hemorrhage, but had a slightly higher incidence infratentorially (7%) than supratentorially (5%). Rupture was due to arterial bleeding in 18 patients (56%), premature occlusion of a major draining vein in 10 (31%), and nidal penetration in 4 (13%). In 14 cases (44%), bleeding control was abandoned and the AVM was removed immediately ("commando resection"). The incidence of intraoperative rupture was highest during the initial 5-year period (9%) and dropped to 3% and 4% in the second and third 5-year periods, respectively. Ruptures due to premature venous occlusion and nidal penetration diminished with experience, whereas those due to arterial bleeding remained steady. Despite intraoperative rupture, 90% of AVMs were completely resected initially and all of them ultimately. Intraoperative rupture negatively impacted outcome, with significantly higher final modified Rankin Scale scores (mean 2.8) than in the overall cohort (mean 1.5; p < 0.001). CONCLUSIONS Intraoperative AVM rupture is an uncommon complication caused by pathological arterial anatomy and by technical mistakes in judging the dissection distance from the AVM margin and in mishandling or misinterpreting the draining veins. The decrease in intraoperative rupture rate over time suggests the existence of a learning curve. In contrast, intraoperative rupture due to arterial bleeding reflects the difficulty with dysplastic feeding vessels and deep perforator anatomy rather than neurosurgeon experience. The results demonstrate that intraoperative AVM rupture negatively impacts patient outcome, and that skills in managing this catastrophe are critical.
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Affiliation(s)
- Ramon Torné
- Department of Neurological Surgery, Vall d'Hebron Hospital, Universitat Autònoma de Barcelona, Spain
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Diffuse Patterns of Nonaneurysmal Subarachnoid Hemorrhage Originating from the Basal Cisterns Have Predictable Vasospasm Rates Similar to Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2015; 24:795-801. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/22/2014] [Accepted: 11/14/2014] [Indexed: 11/20/2022] Open
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Stapleton CJ, Walcott BP, Butler WE, Ogilvy CS. Neurological outcomes following intraprocedural rerupture during coil embolization of ruptured intracranial aneurysms. J Neurosurg 2015; 122:128-35. [PMID: 25361491 DOI: 10.3171/2014.9.jns14616] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraprocedural rerupture (IPR) of intracranial aneurysms during coil embolization is associated with significant periprocedural disability and death. However, whether this morbidity and mortality are secondary to an increased risk of vasospasm and hydrocephalus is unknown. The authors undertook this study to determine the in-hospital and long-term neurological outcomes for patients with aneurysmal subarachnoid hemorrhage (SAH) treated with coil embolization who suffer aneurysm rerupture during treatment. METHODS The records of 156 patients admitted with SAH from previously untreated, ruptured, intracranial aneurysms and treated with endovascular coiling between January 2007 and January 2014 were retrospectively reviewed. Twelve patients (7.7%) experienced IPR during coil embolization. RESULTS Compared with the cohort of patients with uncomplicated coil embolization procedures, patients with aneurysm rerupture were more likely to require external ventricular drain (EVD) placement (91.7% vs 58.3%, p = 0.02) and postprocedural EVD placement (36.4% vs 7.1%, p = 0.01), to undergo permanent ventriculoperitoneal shunt placement (50.0% vs 18.8%, p = 0.02), to develop symptomatic vasospasm (50.0% vs 18.1%, p = 0.02), and to have longer lengths of hospital stay (median 21.5 days vs 15.0 days, p = 0.04). Admission Hunt and Hess, modified Fisher, and Barrow Neurological Institute grades did not differ between the 2 cohorts, nor did long-term functional neurological outcomes as assessed by the modified Rankin Scale. CONCLUSIONS Intraprocedural rerupture during coil embolization for ruptured intracranial aneurysms is associated with an increased risk of symptomatic vasospasm and need for temporary and permanent cerebrospinal fluid diversion for hydrocephalus.
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