Reversal of intraoperative arterial thrombosis with a fibrinolytic agent when treating large and giant partially thrombosed aneurysms of the middle cerebral artery

Risk Factors and Clinical Significance of Ultra-Long-Term Microischemia After Intracranial Aneurysm Embolization

INTRODUCTION

This study aimed to explore influencing factors and clinical significance of ultra-long-term microischemia following intracranial aneurysm (IA) embolization and establish a theoretical foundation for reducing both the incidence of ultra-long-term microischemia and cognitive dysfunction in patients post embolization.

METHODS

A retrospective analysis was conducted on data from 147 patients who received endovascular treatment for IAs. Patients were categorized into microischemic and control (non-microischemic) groups on the based on the findings of high-resolution magnetic resonance vessel wall imaging (HR-VWI) examinations performed 3 days postoperatively and 6 months postoperatively. Risk factors for the occurrence of ultra-long-term microischemia were determined by univariate analysis and multivariate logistic regression analysis.

RESULTS

Out of 147 patients included in the study, 51 (34.69%) developed microischemia while the remaining 96 (65.31%) did not experience this condition. Analysis revealed that factors such as sex, age, history of underlying diseases (hypertension, diabetes mellitus), aneurysmal site characteristics, the presence or absence of stenosis in the aneurysm-bearing artery, modified Fisher score at admission, Barthel's index at discharge, immunoinflammatory index at 3 days postoperatively and at the 6-month follow-up, the presence or absence of aneurysmal wall enhancement, and the presence or absence of aneurysmal lumen showed no statistically significant differences between the two groups (all P > 0.05). By contrast, variables like in operative time, rupture status of the aneurysm before surgery according to World Federation of Neurologic Surgeons (WFNS) grade, aneurysm size, number of stents used, number of guidewires and catheters used, and Evans index between the two groups were found to have statistically significant disparities between those who developed microischemia and those who did not (P < 0.05). A subsequent multivariate analysis revealed that aneurysm size, Evans index, and the number of stents used were independent risk factors for the occurrence of ultra-long-term microischemia after surgical intervention of aneurysms (P < 0.05). The receiver operating characteristic (ROC) curves of the patients were constructed on the basis of risk factors determined through multivariate logistic regression analysis. Results indicated that aneurysm size (area under ROC curve (AUC) 0.619, sensitivity 94.7%, specificity 17.1%, P = 0.049), Evans index (AUC 0.670, sensitivity 96.4%, specificity 26.8%, P = 0.004), and number of stents (AUC 0.639, sensitivity 44.6%, specificity 90.2%, P < 0.001) effectively predicted the occurrence of microischemia. The incidence of cognitive dysfunction was higher in the microischemic group than in the control group (P < 0.05), and a greater number of microischemic foci was associated with a higher incidence of cognitive dysfunction. The proportion of microschemia foci in the thalamus and basal ganglia in patients with cognitive dysfunction (60.87%) was significantly higher than that in patients without cognitive dysfunction (34.55%) (P < 0.05).

CONCLUSION

Aneurysm size, Evans index > 0.3, and the quantity of stents were independent risk factors for the occurrence of ultra-long-term microischemia after aneurysm embolization and provided good predictive performance. Cognitive dysfunction was closely associated with microischemia, with its severity increasing with an increase in the number of ischemic foci.

[Thrombectomy without temporary clipping for giant partially thrombosed saccular aneurysms]

Cerebral aneurysm thrombosis is one of the factors increasing the risk of microsurgical treatment. Thrombi and calcifications within the aneurysm neck prevent adequate clipping and should be removed before the procedure. At the same time, the process of thrombectomy is difficult and time consuming that increases duration of temporary arterial clipping and risk of cerebral ischemia.

OBJECTIVE

To evaluate the results of thrombectomy without temporary arterial clipping for giant aneurysms of anterior brain circulation.

MATERIAL AND METHODS

Four patients with giant partially thrombosed saccular aneurysms underwent thrombectomy without temporary clipping followed by neck clipping. In all cases, the aneurysm was thrombosed by more than 80-90% of its baseline volume, and aneurysm neck contained parietal thrombi from all sides. Mean duration of thrombectomy from aneurysm opening to bleeding and temporary clipping of the parent artery was 82 minutes, time of temporary clipping was about 12 minutes.

RESULTS

Favorable clinical and radiological postoperative results were obtained in all patients. The authors present a scheme of surgical stages and video presentation involving the main surgical aspects of this procedure.

CONCLUSION

Thrombectomy without temporary clipping of the parent artery is an effective technique for microsurgical treatment of giant partially thrombosed saccular intracranial aneurysms. Since most thrombi are removed without bleeding, duration of temporary blood flow discontinuation in the parent artery is significantly reduced. Therefore, we decrease the risk of cerebral ischemia. This technique can be useful in microsurgical treatment of complex aneurysms of the middle cerebral and internal carotid arteries, as well as other aneurysms.

Mechanical clot dissolution technique for surgical clip-related occlusions: An emergent triple-step approach

Cerebral ischemia following clipping of cerebral aneurysms constitutes major cause of morbidity and mortality. Clip-related injury to vessel, postoperative clip rotation, prolonged temporary occlusion, intraoperative rupture, and vasospasm are some etiological factors compromising forward flow in parent or branch vessel. On suspicion of compromised forward flow, immediate intraoperative evaluation is done to detect the cause of vascular compromise and further management is done by microsurgical or endovascular means. We describe a case of ruptured distal anterior cerebral artery (ACA) aneurysm complicated by occlusion of ACA after surgical clipping. The patient was managed by endovascular means by combined technique of intra-arterial nimodipine, antiplatelet infusion, and mechanical clot disruption using J-tip microwire.