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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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Cortez GM, Benalia VHC, Sauvageau E, Aghaebrahim A, Pederson JM, Hanel RA. Diffusion-weighted imaging lesions after intracranial aneurysm treatment with Pipeline Flex and Pipeline Flex with Shield technology: a retrospective cohort analysis. J Neurointerv Surg 2024; 16:385-391. [PMID: 37197932 DOI: 10.1136/jnis-2023-020250] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/03/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND The Pipeline Flex embolization device with Shield technology (PED Shield) is the first flow diverter for brain aneurysm treatment approved in the United States using surface-modified technology. The effect of PED Shield on decreasing perioperative diffusion-weighted imaging positive (DWI+) hits, as a marker for in-human decrease thrombogenicity, is unclear. OBJECTIVE To determine if the number of periprocedural DWI+ lesions differs between patients with an aneurysm treated with PED Flex and PED Shield. METHODS This retrospective study compares the outcomes of consecutive patients with an aneurysm treated with PED Flex and PED Shield. The primary outcome of interest was the occurrence of DWI+ lesions. We also assessed potential predictors of DWI+ lesions and compared the outcomes between on-label and off-label treatment indications. RESULTS 89 patients were included, 48 (54%) treated with PED Flex and 41 (46%) with PED Shield. After matching, the incidence of DWI+ lesions was 61% and 62% for the PED Flex and PED Shield groups, respectively. Results were consistent across each model with no significant differences in DWI+ lesions between treatment groups, and effect sizes ranging from OR=1.08 (95% CI 0.41 to 2.89) after propensity score matching to OR=1.84 (95% CI 0.65 to 5.47) after multivariable regression. Multivariable models demonstrated reduced DWI+ lesions with balloon-assisted therapies and posterior circulation treatment, while a significant linear relationship was encountered with fluoroscopy time. CONCLUSION There was no significant difference in the incidence of perioperative DWI+ lesions between patients with an aneurysm treated with PED Flex and PED Shield. Larger cohorts are likely needed to demonstrate differences between the devices.
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Affiliation(s)
- Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Victor H C Benalia
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - John Michael Pederson
- Superior Medical Experts, Inc, St. Paul, Minnesota, USA
- Nested Knowledge, Inc, St. Paul, Minnesota, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
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Habtezghi AB, Ghozy S, Bilgin C, Kobeissi H, Kadirvel R, Kallmes DF. DWI-Detected Ischemic Lesions after Endovascular Treatment for Cerebral Aneurysms: An Updated Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2023; 44:1256-1261. [PMID: 37827721 PMCID: PMC10631525 DOI: 10.3174/ajnr.a8024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND PURPOSE DWI-detected ischemic lesions are potential complications of endovascular procedures that are performed to treat intracranial aneurysms. We completed a systematic review and meta-analysis to identify the occurrence of DWI-detected ischemic lesions after endovascular treatment for intracranial aneurysms. MATERIALS AND METHODS A systematic literature search of PubMed, the Web of Science, EMBASE, and Scopus between January 2000 and June 2022 of post-endovascular procedures for intracranial aneurysm studies was conducted using the Nested Knowledge AutoLit software. The main outcome was DWI-detected ischemic lesions within 5 days of the procedures. Information regarding associated risk factors such as the type of procedure, patient demographics, and aneurysm characteristics was also collected. RESULTS Twenty-nine studies with 2686 patients were included. The overall incidence of DWI ischemic lesions was 47.0% (95% CI, 39.6%-55.8%). The highest rate of lesions was seen with flow diversion at 62.4% (95% CI, 48.4%-80.5%), followed by complex procedures at 49.3% (95% CI, 29.5%-82.1%), stent-assisted coiling at 47.5% (95% CI, 34.6%-65.3%), simple coiling at 47.1% (95% CI, 35.7%-62.3%), and balloon-assisted coiling at 37.0% (95% CI, 28.3%-48.4%). The differences among different techniques were not statistically significant; however, there was significant heterogeneity and a significant risk of publication bias among included studies. CONCLUSIONS Many patients who undergo endovascular procedures for intracranial aneurysms present with new postprocedural DWI-detected ischemic lesions, regardless of the endovascular procedure used. Future studies and meta-analyses are needed to investigate early and long-term outcomes of such small infarcts.
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Affiliation(s)
- Abiel Berhe Habtezghi
- From the Department of Radiology (A.B.H., S.G., C.B., H.K., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Sherief Ghozy
- From the Department of Radiology (A.B.H., S.G., C.B., H.K., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Cem Bilgin
- From the Department of Radiology (A.B.H., S.G., C.B., H.K., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Hassan Kobeissi
- From the Department of Radiology (A.B.H., S.G., C.B., H.K., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Ramanathan Kadirvel
- From the Department of Radiology (A.B.H., S.G., C.B., H.K., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, Minnesota
| | - David F Kallmes
- From the Department of Radiology (A.B.H., S.G., C.B., H.K., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
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Kanazawa R, Yoshihara T, Uchida T, Higashida T, Arai N, Ohbuchi H, Takahashi Y. Thromboembolic complications during and after embolization of unruptured aneurysms: A chronological outcome in periprocedural thromboembolic events. Surg Neurol Int 2023; 14:362. [PMID: 37941641 PMCID: PMC10629294 DOI: 10.25259/sni_625_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023] Open
Abstract
Background Ischemic complications develop after elective coil embolization procedures at a certain rate. The prevention of these events has been a longstanding issue for many interventional neuroradiologists. This study aimed to clarify whether procedural ischemic events after unruptured aneurysm embolization decrease over time with perioperative anti-thromboembolic treatment or surgical experience. Methods This study included patients with cerebral aneurysms in our institution between July 2012 and June 2020. Dual-antiplatelet therapy (DAPT) was performed (Phase 1). Thromboembolic events developed at a certain rate; thus, rivaroxaban was administered with single-antiplatelet therapy (SAPT) to improve thromboembolic results (Phase 2), showing better outcomes than in Phase 1. Subsequently, DAPT was administered again (Phase 3). Ischemic complications were evaluated in each phase or compared between the DAPT group and the direct oral anticoagulant (DOAC) with the clopidogrel (DOAC+SAPT) group. Results Relatively, fewer symptomatic ischemic events were noted in Phase 2 or the DOAC+SAPT group, but the outcome was not better in Phase 3 than in Phase 2. Symptomatic complications were more common in Phase 3 than in Phases 1 and 2. Conclusion Ischemic complications occurred at a certain rate after endovascular procedures for unruptured aneurysms. The incidence did not decrease over time; particularly, standard DAPT plus postoperative anti-thromboembolic medication did not adequately decrease complications in Phase 3 compared to Phases 1 and 2. Therefore, accumulated experience or a learning curve could not explain the results. DOAC administration might decrease the risk of these events, but further accumulation of evidence or prospective investigation is warranted.
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Affiliation(s)
| | - Tomoyuki Yoshihara
- Department of Emergency and Critical Care Medicine, Kansai Medical University General Medical Center, Osaka, Japan
| | - Takanori Uchida
- Department of Neurosurgery, Nagareyama Central Hospital, Chiba, Japan
| | | | - Naoyuki Arai
- Department of Neurosurgery, Medical Center Adachi, Tokyo Women’s Medical University, Tokyo, Japan
| | - Hidenori Ohbuchi
- Department of Neurosurgery, Medical Center Adachi, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yuichi Takahashi
- Department of Neurosurgery, Sassa General Hospital, Nishitokyo, Japan
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Rossitto CP, Vasan V, Downes MH, Yildiz S, Smith CJ, Liang JW, Schupper AJ, Hardigan T, Liu X, Ali M, Chapman EK, Devarajan A, Odland IC, Kellner CP, Mocco J. Preoperative cerebral angiography nearly doubles the rate of diffusion-weighted imaging lesion detection following minimally invasive surgery for intracerebral hemorrhage. J Neurointerv Surg 2023:jnis-2023-020687. [PMID: 37696596 DOI: 10.1136/jnis-2023-020687] [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: 06/15/2023] [Accepted: 08/14/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH. METHODS Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIs were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. RESULTS DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02). CONCLUSIONS In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH.
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Affiliation(s)
- Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Margaret H Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sema Yildiz
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Colton J Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John W Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xinyan Liu
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ian C Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Alghamdi I, Dmytriw AA, Amirabadi A, Lebarron S, Rea V, Parra-Fariñas C, Muthusami P. Clinical and subclinical microemboli following neuroangiography in children. J Neurointerv Surg 2023:jnis-2023-020686. [PMID: 37562819 DOI: 10.1136/jnis-2023-020686] [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: 06/14/2023] [Accepted: 07/27/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND To assess the frequency, imaging appearances, and risk factors of brain microemboli following pediatric neuroangiography, as assessed by early diffusion-weighted MRI imaging (DWI). METHODS This single-center, retrospective analysis investigated early DWI post-pediatric neuroangiography. Patients aged 0-18 years who had diagnostic neuroangiography and DWI within a week postprocedure were included. Data on clinical and procedural parameters and MRI findings were recorded. Univariate and multivariate analyses were performed on the following risk factors: age, weight, vasculopathy, antiplatelet drug use, access type, intraprocedural heparin, procedure duration, neck arteries catheterized, and angiographic runs. A p-value<0.05 indicated statistical significance. RESULTS Eighty-two children were included (40.2% female), mean age 10.1±4.5 years (range: 7 months-17 years). There were no intraprocedural thromboembolic complications recognized. DWI positivity was seen following 3.6% (3/82) procedures: two with transient symptoms, and one instance of silent microemboli. There were no territorial infarcts or clinical stroke. Children with underlying vasculopathy had a higher risk of microemboli from angiography than children without vasculopathy (OR 31.6, p=0.02), and the OR of microemboli following transradial angiography was 79.1 (p=0.005) as compared with transfemoral angiography. Univariate and multivariate analysis showed a significant association between microemboli and number of angiographic runs (p=0.004). Follow-up MRI in all three patients showed no residual abnormal signal. CONCLUSIONS Cerebral microemboli are unusual following uncomplicated neuroangiography in children. However, in the presence of underlying vasculopathy and with transradial technique, the incidence approaches that reported in the adult literature. An increased association with the number of angiographic runs is an important and controllable factor.
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Affiliation(s)
- Ibrahim Alghamdi
- Divisions of Neuroradiology & Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Adam A Dmytriw
- Divisions of Neuroradiology & Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Afsaneh Amirabadi
- Divisions of Neuroradiology & Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Samantha Lebarron
- Divisions of Neuroradiology & Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vanessa Rea
- Divisions of Neuroradiology & Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carmen Parra-Fariñas
- Divisions of Neuroradiology & Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Prakash Muthusami
- Divisions of Neuroradiology & Neurointervention, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Mo L, Yue J, Yu W, Liu X, Tan C, Peng W, Ding X, Chen L. Diffusion-weighted imaging lesions after endovascular treatment of cerebral aneurysms: A network meta-analysis. Front Surg 2023; 9:964191. [PMID: 36726950 PMCID: PMC9885006 DOI: 10.3389/fsurg.2022.964191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/21/2022] [Indexed: 01/17/2023] Open
Abstract
Background Thromboembolism is one of the common complications in endovascular treatments including coiling alone, stent-assisted coiling (SAC), balloon-assisted coiling (BAC), and flow-diverting (FD) stents. Such treatments are widely used in intracranial aneurysms (IAs), which usually present as positive lesions in diffusion-weighted imaging (DWI). Whether these adjunctive techniques increase postprocedural DWI-positive lesions after endovascular treatment remains unclear. Methods A thorough electronic search for the literature published in English between January 2000 and October 2022 was conducted on PubMed, Medline, and EMBASE. Eighteen studies (3 cohort studies and 15 case-control studies) involving 1,843 patients with unruptured IAs (UIAs) were included. We performed a frequentist framework network meta-analysis (NMA) to compare the rank risks of cerebral thromboembolism of the above four endovascular treatments. The incoherence test was used to analyze the statistical disagreement between direct and indirect evidence. Funnel plots were used to analyze publication bias. Results The incidences of DWI lesions in patients who received FD stents, SAC, BAC, and coiling alone were 66.1% (109/165), 37.6% (299/795), 31.1% (236/759), and 25.6% (236/921). The incidence of DWI lesions in patients who received FD stents was higher than that in patients who received SAC [OR: 2.40; 95% CI (1.15, 5.00), P < 0.05], BAC [OR: 2.62; 95% CI (1.19, 5.77), P < 0.05], or coiling alone [OR: 2.77; 95% CI (1.26, 6.07), P < 0.05]. The incoherence test showed preferable consistency in this NMA. No obvious publication bias was found in the funnel plot. Conclusion FD stent placement brings more ischemic lesions identified by DWI than any other procedures for patients with UIA. The characteristics of FD stents may result in a high incidence of DWI lesions.
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Affiliation(s)
- Lijuan Mo
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianhe Yue
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wanli Yu
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Changhong Tan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wuxue Peng
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xueying Ding
- Department of Neurology, Shenzhen University General Hospital, Shenzhen, China
| | - Lifen Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China,Correspondence: Lifen Chen
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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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Nakamura Y, Nishijima S, Kuroda M, Nakayama T, Tsuruta R, Yoshiyama D, Yasumoto Y, Ito Y. Perfusion strategy using axillary or femoral cannulation for minimally invasive cardiac surgery: experience in 270 patients with computed tomography-based criteria. Eur J Cardiothorac Surg 2021; 59:1200-1207. [PMID: 33448282 DOI: 10.1093/ejcts/ezaa469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/18/2020] [Accepted: 11/25/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES In patients with atherosclerotic disease, minimally invasive cardiac surgery using retrograde perfusion for cardiopulmonary bypass via femoral cannulation (FC) carries a higher risk of brain embolization compared with antegrade perfusion. However, guidelines for selecting antegrade versus retrograde perfusion do not exist. We developed a computed tomography (CT)-based perfusion strategy and assessed outcomes. METHODS We studied 270 minimally invasive cardiac surgery patients, aged 68 ± 13, 124 female, body surface area 1.6 ± 0.2 m2. Antegrade perfusion using axillary cannulation (AC) was selected if any of the following preoperative enhanced CT scan criteria were satisfied anywhere in the aorta or iliac arteries: thrombosis thickness >3 mm, thrombosis >one-third of the total circumference and calcification present in the total circumference. FC was selected otherwise. Asymptomatic brain injury was assessed by diffusion-weighted magnetic resonance imaging. RESULTS AC and FC were selected in 95 (35%) and 175 patients, respectively. AC patients were 10 years older (P < 0.001) and had higher EuroSCORE II (2.7 ± 3.4 vs 1.7 ± 1.9, P = 0.002). The median cardiopulmonary time and cross-clamp times were not significantly different. No patients died in hospital. There was no immediate stroke in either group during 48 h after surgery. Asymptomatic brain injury was detected in 25 (26%) and 27 (15%) AC and FC patients, respectively, P = 0.03. CONCLUSIONS We believe our CT-based perfusion strategy using AC or FC minimized brain embolic rates. AC can be a good alternative to prevent brain embolization for minimally invasive cardiac surgery patients with advanced atherosclerotic disease.
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Affiliation(s)
- Yoshitsugu Nakamura
- Department of Cardiovascular Surgery, Chibanishi General Hospital, Matsudo-city, Chiba, Japan
| | - Shuhei Nishijima
- Department of Cardiovascular Surgery, Chibanishi General Hospital, Matsudo-city, Chiba, Japan
| | - Miho Kuroda
- Department of Cardiovascular Surgery, Chibanishi General Hospital, Matsudo-city, Chiba, Japan
| | - Taisuke Nakayama
- Department of Cardiovascular Surgery, Chibanishi General Hospital, Matsudo-city, Chiba, Japan
| | - Ryo Tsuruta
- Department of Cardiovascular Surgery, Chibanishi General Hospital, Matsudo-city, Chiba, Japan
| | - Daiki Yoshiyama
- Department of Cardiovascular Surgery, Chibanishi General Hospital, Matsudo-city, Chiba, Japan
| | - Yuto Yasumoto
- Department of Cardiovascular Surgery, Chibanishi General Hospital, Matsudo-city, Chiba, Japan
| | - Yujiro Ito
- Department of Cardiovascular Surgery, Chibanishi General Hospital, Matsudo-city, Chiba, Japan
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Veken JVD. Commentary on: Result of coiling versus clipping of unruptured anterior communicating artery aneurysms treated by a hybrid vascular neurosurgeon. J Cerebrovasc Endovasc Neurosurg 2021; 23:169-171. [PMID: 33975426 PMCID: PMC8256024 DOI: 10.7461/jcen.2021.e2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/16/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jorn Van Der Veken
- Department of Neurosurgery, Flinders Medical Centre, Bedford Park, Australia
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Mohammad Seyedsaadat S, Rangel Castilla L, Lanzino G, Cloft HJ, Blezek DJ, Theiler A, Kadirvel R, Brinjikji W, Kallmes DF. Remote ischemic preconditioning for elective endovascular intracranial aneurysm repair: a feasibility study. Neuroradiol J 2019; 32:166-172. [PMID: 30942660 DOI: 10.1177/1971400919842059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Remote ischemic preconditioning has been proposed as a possible potential treatment for ischemic stroke. However, neuroprotective benefits of the pre-procedural administration of remote ischemic preconditioning have not been investigated in patients undergoing an elective endovascular intracranial aneurysm repair procedure. This study investigated the safety and feasibility of remote ischemic preconditioning in patients with an unruptured intracranial aneurysm who undergo elective endovascular treatment. METHODS In this single-center prospective study, patients with an unruptured intracranial aneurysm undergoing elective endovascular treatment with flow diverters or coiling were recruited. Patients received three intermittent cycles of 5 minutes arm ischemia followed by reperfusion using manual blood cuff inflation/deflation less than 5 hours prior to endovascular treatment. Patients were monitored and followed up for remote ischemic preconditioning-related adverse events and ischemic brain lesions by diffusion -weighted magnetic resonance imaging within 48 hours following endovascular treatment. RESULTS A total of seven patients aged 60 ± 5 years with an unruptured intracranial aneurysm successfully completed a total of 21 sessions of remote ischemic preconditioning and the required procedures. Except for two patients who developed skin petechiae over their arms, no other serious procedure-related adverse events were observed as a result of the remote ischemic preconditioning procedure. On follow-up diffusion -weighted magnetic resonance imaging, a total of 19 ischemic brain lesions with a median (interquartile range) volume of 245 (61-466) mm3 were found in four out of seven patients. CONCLUSIONS The application of remote ischemic preconditioning prior to endovascular intracranial aneurysm repair was well tolerated, safe and clinically feasible. Larger sham-controlled clinical trials are required to determine the safety and efficacy of this therapeutic strategy in mitigating ischemic damage following endovascular treatment of intracranial aneurysms.
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Affiliation(s)
| | - Leonardo Rangel Castilla
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Lanzino
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Harry J Cloft
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Amy Theiler
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - David F Kallmes
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Konczalla J, Platz J, Fichtlscherer S, Mutlak H, Strouhal U, Seifert V. Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: results of an interdisciplinary prospective trial. J Neurosurg 2018; 128:1741-1752. [DOI: 10.3171/2016.11.jns161420] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVETo date, treatment of complex unruptured intracranial aneurysms (UIAs) remains challenging. Therefore, advanced techniques are required to achieve an optimal result in treating these patients safely. In this study, the safety and efficacy of rapid ventricular pacing (RVP) to facilitate microsurgical clip reconstruction was investigated prospectively in a joined neurosurgery, anesthesiology, and cardiology study.METHODSPatients with complex UIAs were prospectively enrolled. Both the safety and efficacy of RVP were evaluated by recording cardiovascular events and outcomes of patients as well as the amount of aneurysm occlusion after the surgical clip reconstruction procedure. A questionnaire was used to evaluate aneurysm preparation and clip application under RVP.RESULTSTwenty patients (mean age 51.6 years, range 28–66 years) were included in this study. Electrode positioning was easy in 19 (95%) of 20 patients, and removal of electrodes was easily accomplished in all patients (100%). No complications associated with the placement of the pacing electrodes occurred, such as cardiac perforation or cardiac tamponade. RVP was applied in 16 patients. The mean aneurysm size was 11.1 ± 5.5 mm (range 6–30 mm). RVP proved to be a very helpful tool in aneurysm preparation and clip application in 15 (94%) of 16 patients. RVP was used for a mean duration of 60 ± 25 seconds, a mean heart rate of 173 ± 23 bpm (range 150–210 bpm), and a reduction of mean arterial pressure to 35–55 mm Hg. RVP leads to softening of the aneurysm sac facilitating its mobilization, clip application, and closure of the clip blades. In 2 patients, cardiac events were documented that resolved without permanent sequelae in both. In every patient with successful RVP (n = 14) a total or near-total aneurysm occlusion was documented. In the 1 patient in whom the second RVP failed due to pacemaker electrode dislocation, additional temporary clipping was required to secure the aneurysm, but was not as sufficient as RVP. This led to an incomplete clipping of the aneurysm and finally a remnant on postoperative digital subtraction angiography. A pacemaker lead dislocation occurred in 3 (19%) of 16 patients, but intraoperative repositioning requires less than 20 seconds. Outcome was favorable in all patients according to the modified Rankin Scale.CONCLUSIONSTo the best of the authors’ knowledge this is the first prospective interdisciplinary study of RVP use in patients with UIAs. RVP is an elegant technique that facilitates clip reconstruction in complex UIAs. The safety of the procedure is good. However, because this procedure requires extensive preoperative cardiological workup of the patient and an experienced neurosurgery and neuroanesthesiology team with much cerebrovascular expertise, actually it remains reserved for selected elective cases and highly specialized centers.Clinical trial registration no.: NCT02766972 (clinicaltrials.gov)
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Affiliation(s)
| | | | | | - Haitham Mutlak
- 3Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Ulrich Strouhal
- 3Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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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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Verma A, Verma S, Al-Omran M, Rutka JT. Editorial. To pace or not to pace: that is the question. J Neurosurg 2017; 128:1737-1740. [PMID: 28820307 DOI: 10.3171/2017.1.jns162923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | - James T Rutka
- 3Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada
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