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Sturiale CL, Auricchio AM, Skrap B, Stifano V, Albanese A. The clinical challenge of subarachnoid hemorrhage associated with multiple aneurysms when the bleeding source is not certainly identifiable. J Neurosurg Sci 2024; 68:301-309. [PMID: 34763396 DOI: 10.23736/s0390-5616.21.05609-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Multiple intracranial aneurysms (IAs) are encountered in 20-30% of the subarachnoid hemorrhages (SAH). Neuroimaging and clinical examination are usually sufficient to detect the bleeding source, but sometimes it can be misdiagnosed with catastrophic consequences. METHODS We reviewed our diagnostic work-up for all patients admitted from January 2016 to December 2020 for SAH with multiple IAs accounting for our rate of diagnostic failure. Then, we grouped the patients into 4 categories according to aneurysms topography and described our operative protocol in case of uncertain bleeding origin. RESULTS Sixty-two patients harboring 161 IAs were included. The bleeding source was identified in 56 patients (90.3%), who harbored other 81 bystander aneurysms. In 6 cases (9.7%) with a total of 24 aneurysms we failed the bleeding source identification. According to IAs topography, we grouped the IAs multiplicity in: 1) anterior plus posterior circulation IAs; 2) multiple posterior circulation IAs; 3) bilateral anterior circulation IAs; and 4) multiple ipsilateral anterior circulation IAs. In case of unidentified bleeding source, key-elements favoring the simultaneous multiple IAs treatment were their number, morphology, topography, clinicians' experience, and management modality as endovascular treatment allows a faster exclusion of multiple IAs distant one each other compared with surgery. MCA involvement represented the more frequent reason to prefer multiple clipping rather than multiple coiling. CONCLUSIONS In a small percentage of patients with SAH with multiple IAs, bleeding source identification can be difficult. Until the routinely availability of new tools such as vessel wall imaging or computational fluid dynamics, an experienced neurovascular team and strategies aiming to simultaneously exclude multiple IAs remain mandatory.
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Affiliation(s)
- Carmelo L Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy -
| | - Anna M Auricchio
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Benjamin Skrap
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Stifano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessio Albanese
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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2
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Deshmukh AS, Priola SM, Katsanos AH, Scalia G, Costa Alves A, Srivastava A, Hawkes C. The Management of Intracranial Aneurysms: Current Trends and Future Directions. Neurol Int 2024; 16:74-94. [PMID: 38251053 PMCID: PMC10801587 DOI: 10.3390/neurolint16010005] [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: 10/15/2023] [Revised: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Intracranial aneurysms represent a major global health burden. Rupture of an intracranial aneurysm is a catastrophic event. Without access to treatment, the fatality rate is 50% in the first 30 days. Over the last three decades, treatment approaches for intracranial aneurysms have changed dramatically. There have been improvements in the medical management of aneurysmal subarachnoid haemorrhage, and there has been an evolution of treatment strategies. Endovascular therapy is now the mainstay of the treatment of ruptured intracranial aneurysms based on robust randomised controlled trial data. There is now an expansion of treatment indications for unruptured intracranial aneurysms to prevent rupture with both microsurgical clipping and endovascular treatment. Both microsurgical and endovascular treatment modalities have evolved, in particular with the introduction of innovative endovascular treatment options including flow diversion and intra-saccular flow disruption. These novel therapies allow clinicians to treat more complex and previously untreatable aneurysms. We aim to review the evolution of treatment strategies for intracranial aneurysms over time, and discuss emerging technologies that could further improve treatment safety and functional outcomes for patients with an intracranial aneurysm.
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Affiliation(s)
- Aviraj S. Deshmukh
- Division of Clinical Sciences, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Stefano M. Priola
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Aris H. Katsanos
- Division of Neurology, Hamilton General Hospital, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital of National Importance “Garibaldi”, 95126 Catania, Italy;
| | - Aderaldo Costa Alves
- Division of Neurosurgery, Health Sciences North, Northern Ontario School of Medicine University, Sudbury, ON P3E 2C6, Canada;
| | - Abhilekh Srivastava
- Division of Neurology, Hamilton General Hospital, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Christine Hawkes
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M5S 1A1, Canada;
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Yoshikawa MH, Rabelo NN, Telles JPM, Pipek LZ, Barbosa GB, Barbato NC, Coelho ACSDS, Teixeira MJ, Figueiredo EG. Role of temporary arterial occlusion in subarachnoid hemorrhage outcomes: a prospective cohort study. Acta Cir Bras 2023; 38:e387923. [PMID: 38055387 DOI: 10.1590/acb387923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/25/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Temporary arterial occlusion (TAO) is a widespread practice in the surgical treatment of intracranial aneurysms. This study aimed to investigate TAO's role during ruptured aneurysm clipping as an independent prognostic factor on short- and long-term outcomes. METHODS This prospective cohort included 180 patients with ruptured intracranial aneurysms and an indication of microsurgical treatment. Patients who died in the first 12 hours after admission were excluded. RESULTS TAO was associated with intraoperative rupture (IOR) (odds ratio - OR = 10.54; 95% confidence interval - 95%CI 4.72-23.55; p < 0.001) and surgical complications (OR = 2.14; 95%CI 1.11-4.07; p = 0.01). The group with TAO and IOR had no significant difference in clinical (p = 0.06) and surgical (p = 0.94) complications compared to the group that had TAO, but no IOR. Among the 111 patients followed six months after treatment, IOR, number of occlusions, and total time of occlusion were not associated with Glasgow Outcome Scale (GOS) in the follow-up (respectively, p = 0.18, p = 0.30, and p = 0.73). Among patients who underwent TAO, IOR was also not associated with GOS in the follow-up (p = 0.29). CONCLUSIONS TAO was associated with IOR and surgical complications, being the latter independent of IOR occurrence. In long-term analysis, neither TAO nor IOR were associated with poor clinical outcomes.
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4
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Skrap B, Di Bonaventura R, Di Domenico M, Sturiale CL, Auricchio AM, Maugeri R, Giammalva GR, Iacopino DG, Olivi A, Marchese E, Albanese A. Has intraoperative neuromonitoring changed the surgery for unruptured middle cerebral artery aneurysms? A retrospective comparative study. Neurosurg Rev 2023; 46:191. [PMID: 37535200 PMCID: PMC10400477 DOI: 10.1007/s10143-023-02099-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/30/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
Intraoperative neurophysiological monitoring (IONM) represents one of the available technologies able to assess ischemia and aimed to improve surgical outcome reducing the treatment related morbidity in surgery for intracranial aneurysms. Many studies analyzing the impact of IONM are poised by the heterogeneity bias affecting the cohorts. We report our experience with IONM for surgery of unruptured middle cerebral artery (MCA) aneurysm in order to highlight its influence on functional and radiological outcome and surgical strategy. We retrospectively reviewed all MCA unruptured aneurysms treated between January 2013 and June 2021 by our institutional neurovascular team. Patients were divided into 2 groups according to the use of IONM. A total of 153 patients were included in the study, 52 operated on without IONM and 101 with IONM. The groups did not differ preoperatively regarding clinical status and aneurysm characteristics. Patients operated with IONM had better functional outcomes at discharge as well as at follow-up (p= 0.048, p=0.041) due to lower symptomatic ischemia and better radiological outcome due to lower rate of unexpected aneurysmal remnants (p= 0.0173). The introduction of IONM changed the use of temporary clipping (TeC), increasing its average duration (p= 0.01) improving the safety of dissecting and clipping the aneurysm. IONM in surgery for unruptured MCA aneurysm could improve the efficacy and safety of clipping strategy in the way it showed a role in changing the use of TeC and was associated to the reduction of unexpected aneurysmal remnants' rate and improvement in both short- and long-term patient's outcome.
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Affiliation(s)
- Benjamin Skrap
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Rina Di Bonaventura
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Michele Di Domenico
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Carmelo Lucio Sturiale
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Anna Maria Auricchio
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Giuseppe Roberto Giammalva
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Department of Biomedicine Neurosciences and Advanced Diagnostics, School of medicine, University of Palermo, Palermo, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Alessio Albanese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy
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5
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Baumgart L, Wagner A, Dorier AS, Droese D, Aftahy AK, Wostrack M, Ille S, Meyer B, Krieg SM. Predictive value of IOM in clipping of unruptured intracranial aneurysms - A prospective study from the surgeon's point of view. BRAIN & SPINE 2023; 3:101759. [PMID: 37383469 PMCID: PMC10293320 DOI: 10.1016/j.bas.2023.101759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 06/30/2023]
Abstract
Introduction Intraoperative neuromonitoring (IOM) of motor/somatosensory evoked potentials is a well-established approach for reducing ischemic complications after aneurysm clipping. Research question To determine the predictive validity of IOM for postoperative functional outcome and its perceived added value for intraoperative real-time feedback of functional impairment in the surgical treatment of unruptured intracranial aneurysms (UIAs). Material and methods Prospective study of patients scheduled for elective clipping of UIAs between 02/2019-02/2021. Transcranial motor evoked potentials (tcMEP) were used in all cases, a significant decline was defined as loss of ≥50% in amplitude or 50% latency increase. Clinical data were correlated to postoperative deficits. A surgeon's questionnaire was conceived. Results 47 patients were included, median age 57 years (range 26-76). IOM was successful in all cases. In 87.2%, IOM was stable throughout surgery, although 1 patient (2.4%) demonstrated a permanent postoperative neurological deficit. All patients with an intraoperatively reversible tcMEP-decline (12.7%) showed no surgery-related deficit, regardless of the decline duration (range 0.5-40.0 min; mean: 13.8). Temporary clipping (TC) was performed in 12 cases (25.5%), with a decline in amplitude in 4 patients. After clip-removal, all amplitudes returned to baseline. IOM provided the surgeon with a higher sense of security in 63.8%. Discussion and conclusion IOM remains invaluable during elective microsurgical clipping, particularly during TC of MCA and AcomA-aneurysms. It alerts the surgeon of impending ischemic injury and offers a way of maximizing the time frame for TC. IOM has highly increased surgeons' subjective feeling of security during the procedure.
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Affiliation(s)
- Lea Baumgart
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Anne-Sophie Dorier
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Doris Droese
- Department of Anaesthesiology, Technical University Munich School of Medicine, Munich, Germany
| | - Amir K. Aftahy
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Sebastian Ille
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
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6
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Le K, Heskett C, De Stefano FA, Fry L, Lei C, Dharia A, Brake A, Chatley K, Peterson J, Ebersole K. An Analysis of Landmark Articles Regarding Aneurysms of the Middle Cerebral Artery. World Neurosurg 2023; 171:72-83. [PMID: 36473598 DOI: 10.1016/j.wneu.2022.11.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Aneurysms located on the middle cerebral artery (MCA) range from 22% to 31.5% in prevalence of all aneurysms in the anterior cerebral circulation. This bibliometric analysis summarizes the most cited articles on MCA aneurysms and highlights the landmark publications that contributed to evidence-based practice. METHODS In the execution of this bibliometric-based review article, the Scopus database was used to perform a title-specific, keyword-based search for all publications until August 2022. The keyword "(middle cerebral artery OR MCA) AND aneurysm" was used. Our results were arranged in descending order based on the citation count of the article. The 100 most cited articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty of first author, institution, country of origin, publishing journal, Source Normalized Impact per Paper, and Hirsch index. RESULTS The keyword-based search showed that 1206 articles on MCA aneurysms were published up to August 2022. The top 100 articles were published between 1940 and 2019. The top 100 most cited articles collected a total of 6232 citations with an average of 62.3 citations per article. The rate of self-citations accounted for an average of 5.75% of the total number of citations. CONCLUSIONS The bibliometric analysis provides a quantitative overview of how medical literature and interventions are analyzed in academic medicine. In the present study, we evaluated the global trends in research regarding MCA aneurysms by finding the top 100 most cited articles.
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Affiliation(s)
- Kevin Le
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Cody Heskett
- University of Kansas School of Medicine, Kansas City, Kansas, USA.
| | - Frank A De Stefano
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Lane Fry
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Catherine Lei
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Anand Dharia
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Aaron Brake
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kevin Chatley
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeremy Peterson
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Koji Ebersole
- Department of Neurological Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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7
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Hu L, Quan K, Shi Y, Liu P, Song J, Tian Y, An Q, Liu Y, Li S, Yu G, Fan Z, Luo J, Gu Y, Xu B, Zhu W, Mao Y. Association of Preoperative Vascular Wall Imaging Patterns and Surgical Outcomes in Patients With Unruptured Intracranial Saccular Aneurysms. Neurosurgery 2023; 92:421-430. [PMID: 36637276 DOI: 10.1227/neu.0000000000002219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/31/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND MR vascular wall imaging (VWI) may have prognostic value in patients with unruptured intracranial aneurysms (UIAs). OBJECTIVE To evaluate the value of VWI as a predictor of surgical outcome in patients with UIAs. METHODS This prospective cohort study evaluated surgical outcomes in consecutive patients with UIAs who underwent surgical clipping at a single center. All participants underwent high-resolution VWI and were followed for at least 6 months. The primary clinical outcome was modified Rankin scale (mRS) score 6 months after surgery. RESULTS The number of patients in the no wall enhancement, uniform wall enhancement (UWE), and focal wall enhancement (FWE) groups was 37, 145, and 154, respectively. Incidence of postoperative complications was 15.5% in the FWE group, 12.4% in the UWE group, and 5.4% in the no wall enhancement group. The proportion of patients with mRS score >2 at the 6-month follow-up was significantly higher in the FWE group than in the UWE group (14.3% vs 6.9%; P = .0389). In the multivariate analysis, FWE (odds ratio, 2.573; 95% CI 1.001-6.612) and positive proximal artery remodeling (odds ratio, 10.56; 95% CI 2.237-49.83) were independent predictors of mRS score >2 at the 6-month follow-up. CONCLUSION Preoperative VWI can improve the surgeon's understanding of aneurysm pathological structure. Type of aneurysmal wall enhancement on VWI is associated with clinical outcome and incidence of salvage anastomosis and surgical complications.
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Affiliation(s)
- Liuxun Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yuan Shi
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Peixi Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jianping Song
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yanlong Tian
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Qingzhu An
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Yingjun Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Sichen Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Guo Yu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Zhiyuan Fan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China.,Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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8
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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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9
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Yeung EHL, Piper K, Farooq J, Zhang J, Agazzi S, Van Loveren H, Lau T. Robotic Arm-Protected Microsurgical Pericallosal and Middle Cerebral Artery Aneurysm Clipping: A Technical Note and Case Series. Oper Neurosurg (Hagerstown) 2023; 24:88-93. [PMID: 36519882 DOI: 10.1227/ons.0000000000000447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/20/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Managing intraoperative aneurysm rupture (IAR) during intracranial aneurysm clipping can be challenging given the excessive hemorrhage and limited field of view under the microscope for visualizing the proximal artery and safe temporary clipping. OBJECTIVE To describe the first known use of robotic arm for safeguarding IAR in microsurgical aneurysm clipping. METHODS A robotic arm was used to safeguard 3 microsurgical clipping cases (1 pericallosal and 2 middle cerebral artery) performed by a single surgeon. The device was installed onto the side rail of the operating table along with the clip applier attachment. After dissecting the cerebral artery segment proximal to the aneurysm, a temporary aneurysm clip was loaded and established at the appropriate segment before dissecting distally toward the aneurysm. RESULTS Setup for the robotic arm and temporary clip was simple, quick, precise, and without any unforeseen accommodations needed in all 3 instances. The temporary clip acted as an emergency gate and could be deployed either manually or remotely through a controller. IAR occurred in case 1, and the robotic-assisted temporary clip deployment achieved immediate hemostasis without complications. This method bypassed the need for significant suctioning, packing, and further exploration for safe temporary clipping. Case 2 and 3 demonstrated the feasibility for middle cerebral artery protection and ease of intraoperative readjustment. CONCLUSION This technical note highlights the feasibility and relative ease of using a robotic arm as a safeguard device, and it enables on-demand control of proximal blood flow and may enhance the safety of microsurgical aneurysm procedures.
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Affiliation(s)
- Elton H L Yeung
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Keaton Piper
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Jeffrey Farooq
- USF Health, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Jianjian Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Siviero Agazzi
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Harry Van Loveren
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Tsz Lau
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
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10
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Doron O, Silverstein JW, Likowski D, Kohut K, Ellis JA. Temporary vessel occlusion in cerebral aneurysm surgery guided by direct cortical motor evoked potentials. Acta Neurochir (Wien) 2022; 164:1255-1263. [PMID: 35233664 DOI: 10.1007/s00701-022-05158-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Temporary clipping is an important tool in the vascular neurosurgeon's armamentarium. We routinely utilize intraoperative neurophysiological monitoring (IONM) for complex brain aneurysm surgery cases, relying on direct cortical motor evoked potential (DCMEP) alerts to guide the duration of temporary clipping. Previous studies have argued for relatively short and intermittent temporary clipping strategies. In this study, we sought to assess the maximal permissive temporary clipping time during complex aneurysm surgery. To do this, we assessed patient outcome in relation to temporary clip duration guided by DCMEP. METHODS We queried our prospectively collected neuromonitoring database for anterior circulation aneurysm cases where temporary clipping was utilized by a single cerebrovascular surgeon between 2018 and 2021. Operative and IONM reports were reviewed. Patients in whom the duration of temporary clipping could not be determined were excluded. The operative strategy permissively allowed continuous temporary clipping as long as no neuromonitoring alerts were encountered. Maximal permissive parent artery occlusion time (Clipmax) was recorded as the longest duration of tolerated temporary vessel clipping without decrement in DCMEP. RESULTS A total of 41 complex anterior circulation aneurysm clipping cases met criteria for this study. The mean Clipmax for all cases was just over 19 min and did not differ between ruptured and unruptured aneurysms. Initial alert times were not found to be predictive of final permissive temporary clip duration after re-perfusion. In 100% (41/41) of cases, the aneurysm was completely clip occluded without residual on catheter angiogram. Stable or improved modified Rankin Score was achieved in 98% (40/41) of cases at 3-month follow-up. CONCLUSIONS This study demonstrates that using DCMEP can facilitate relatively long but safe temporary clipping durations in complex anterior circulation aneurysm surgery. In the endovascular era with only a limited subset of technically challenging aneurysms needing open surgical treatment, extended permissive temporary clipping guided by DCMEPs can significantly enhance a surgeon's ability to achieve excellent technical and clinical outcomes.
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Affiliation(s)
- Omer Doron
- Department of NeurosurgeryZucker School of Medicine at Hofstra/NorthwellThird Floor, Lenox Hill Hospital, 130 East 77th Street, Black Hall Bldg, New York, NY, 10075, USA
- Biomedical Engineering Department, The Iby and Aladar Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Justin W Silverstein
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
- Neuro Protective Solutions, New York, NY, USA
| | - Desir Likowski
- Department of NeurosurgeryZucker School of Medicine at Hofstra/NorthwellThird Floor, Lenox Hill Hospital, 130 East 77th Street, Black Hall Bldg, New York, NY, 10075, USA
| | | | - Jason A Ellis
- Department of NeurosurgeryZucker School of Medicine at Hofstra/NorthwellThird Floor, Lenox Hill Hospital, 130 East 77th Street, Black Hall Bldg, New York, NY, 10075, USA.
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11
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Yoshikawa MH, Rabelo NN, Telles JPM, Pipek LZ, Barbosa GB, Barbato NC, da Silva Coelho ACS, Teixeira MJ, Figueiredo EG. Temporary arterial occlusion (TAO) as independent prognostic factor in unruptured aneurysm surgery: A cohort study. J Clin Neurosci 2022; 99:78-81. [DOI: 10.1016/j.jocn.2022.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/09/2022] [Accepted: 02/28/2022] [Indexed: 11/15/2022]
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12
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Wipplinger C, Wipplinger TM, Griessenauer CJ. Commentary: The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. Neurosurgery 2022; 90:e118-e120. [PMID: 35199653 DOI: 10.1227/neu.0000000000001888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Tamara M Wipplinger
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, New York, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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13
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Evaluation of multimodal intraoperative neurophysiologic monitoring during supratentorial aneurysm surgery: a comparative study. Neurosurg Rev 2022; 45:2161-2173. [PMID: 35022937 DOI: 10.1007/s10143-021-01710-2] [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: 05/23/2021] [Revised: 08/13/2021] [Accepted: 11/27/2021] [Indexed: 10/19/2022]
Abstract
The objective of this study is to determine the role of multimodal intraoperative neurophysiologic monitoring (IONM) in the overall outcome of intracranial aneurysms surgery, and the risk factors associated with ischemic complications. We grouped 268 ruptured and unruptured intracranial aneurysms surgically treated at our institution into 2 cohorts, based on the use of IONM (180; 67.16%) or non-use of IONM (88; 32.84%). The IONM technique used was multimodal: electroencephalogram (EEG), somatosensory evoked potentials (SSEPs), transcranial (TES), and direct cortical (DCS) stimulation motor evoked potentials (MEPs). There was a significant difference, with a reduction in perioperative strokes (p = 0.011) and better motor surgery-related outcome in the IONM group (p = 0.016). Independent risk factors identified for surgery ischemic complications were temporary clipping time ≥ 6'05″ (odds ratio [OR]: 3.03; 95% CI: 1.068-8.601; p = 0.037), aneurysm size ≥ 7.5 mm (OR: 2.65; 95% CI: 1.127-6.235; p = 0.026), and non-use of IONM (OR: 2.79; 95% CI: 1.171-6.636; p = 0.021). Conversely, aneurysm rupture was not detected as an independent risk factor (OR: 2.5; 95% CI: 0.55-4.55; p = 0.4). Longer temporary clipping time, larger aneurysm size, and the non-use of IONM could be considered as risk factors for ischemic complications during microsurgical clipping. A standardized designed protocol including multimodal IONM with DCS provides continuous information about blood supply and allows reduction of treatment-related morbidity. Multimodal IONM is a valuable technique in intracranial aneurysm surgery.
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14
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Ma K, Bebawy JF. Electroencephalographic Burst-Suppression, Perioperative Neuroprotection, Postoperative Cognitive Function, and Mortality: A Focused Narrative Review of the Literature. Anesth Analg 2021; 135:79-90. [PMID: 34871183 DOI: 10.1213/ane.0000000000005806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Burst-suppression is an electroencephalographic pattern that results from a diverse array of pathophysiological causes and/or metabolic neuronal suppression secondary to the administration of anesthetic medications. The purpose of this review is to provide an overview of the physiological mechanisms that underlie the burst-suppression pattern and to present in a comprehensive way the available evidence both supporting and in opposition to the clinical use of this electroencephalographic pattern as a therapeutic measure in various perioperative settings.
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Affiliation(s)
- Kan Ma
- From the *Department of Anesthesiology and Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology & Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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15
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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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16
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Anesthetic management of unruptured intracranial aneurysms: a qualitative systematic review. Neurosurg Rev 2021; 44:2477-2492. [PMID: 33415519 DOI: 10.1007/s10143-020-01441-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/31/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
Intracranial aneurysms (IA) occur in 3-5% of the general population and may require surgical or endovascular obliteration if the patient is symptomatic or has an increased risk of rupture. These procedures carry an inherent risk of neurological complications, and the outcome can be influenced by the physiological and pharmacological effects of the administered anesthetics. Despite the critical role of anesthetic agents, however, there are no current studies to systematically assess the intraoperative anesthetic risks, benefits, and outcome effects in this population. In this systematic review of the literature, we carefully examine the existing evidence on the risks and benefits of common anesthetic agents during IA obliteration, their physiological and clinical characteristics, and effects on neurological outcome. The initial search strategy captured a total of 287 published studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 28 studies were included in the final report. Our data showed that both volatile and intravenous anesthetics are commonly employed, without evidence that either is superior. Although no specific anesthetic regimens are promoted, their unique neurological, cardiovascular, and physiological properties may be critical to the outcome in vulnerable patients. In particular, patients at risk for perioperative ischemia may benefit from timely administration of anesthetic agents with neuroprotective properties and optimization of their physiological parameters. Further studies are warranted to examine if these anesthetic regimens can reduce the risk of neurological injury and improve the overall outcome in these patients.
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17
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Lobo FA, Vacas S, Rossetti AO, Robba C, Taccone FS. Does electroencephalographic burst suppression still play a role in the perioperative setting? Best Pract Res Clin Anaesthesiol 2020; 35:159-169. [PMID: 34030801 DOI: 10.1016/j.bpa.2020.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/21/2020] [Accepted: 10/27/2020] [Indexed: 12/18/2022]
Abstract
With the widespread use of electroencephalogram [EEG] monitoring during surgery or in the Intensive Care Unit [ICU], clinicians can sometimes face the pattern of burst suppression [BS]. The BS pattern corresponds to the continuous quasi-periodic alternation between high-voltage slow waves [the bursts] and periods of low voltage or even isoelectricity of the EEG signal [the suppression] and is extremely rare outside ICU and the operative room. BS can be secondary to increased anesthetic depth or a marker of cerebral damage, as a therapeutic endpoint [i.e., refractory status epilepticus or refractory intracranial hypertension]. In this review, we report the neurophysiological features of BS to better define its role during intraoperative and critical care settings.
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Affiliation(s)
- Francisco Almeida Lobo
- Anesthesiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Avenida da Noruega, Lordelo, 5000-508, Vila Real, Portugal.
| | - Susana Vacas
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Reagan UCLA Medical Center, 757 Westwood Plaza #3325, Los Angeles, CA, 90095, USA.
| | - Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital and University of Lausanne, CH-1011, Lausanne, Switzerland.
| | - Chiara Robba
- Azienda Ospedaliera Universitaria San Martino di Genova, Largo Rosanna Benzi,15, 16100, Genova, Italy.
| | - Fabio Silvio Taccone
- Hopital Érasme, Université Libre de Bruxelles, Department of Intensive Care Medicine, Route de Lennik, 808 1070, Brussels, Belgium.
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18
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Abstract
Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.
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19
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Hao Y, Xin M, Feng L, Wang X, Wang X, Ma D, Feng J. Review Cerebral Ischemic Tolerance and Preconditioning: Methods, Mechanisms, Clinical Applications, and Challenges. Front Neurol 2020; 11:812. [PMID: 33071923 PMCID: PMC7530891 DOI: 10.3389/fneur.2020.00812] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 06/29/2020] [Indexed: 12/13/2022] Open
Abstract
Stroke is one of the leading causes of morbidity and mortality worldwide, and it is increasing in prevalence. The limited therapeutic window and potential severe side effects prevent the widespread clinical application of the venous injection of thrombolytic tissue plasminogen activator and thrombectomy, which are regarded as the only approved treatments for acute ischemic stroke. Triggered by various types of mild stressors or stimuli, ischemic preconditioning (IPreC) induces adaptive endogenous tolerance to ischemia/reperfusion (I/R) injury by activating a multitude cascade of biomolecules, for example, proteins, enzymes, receptors, transcription factors, and others, which eventually lead to transcriptional regulation and epigenetic and genomic reprogramming. During the past 30 years, IPreC has been widely studied to confirm its neuroprotection against subsequent I/R injury, mainly including local ischemic preconditioning (LIPreC), remote ischemic preconditioning (RIPreC), and cross preconditioning. Although LIPreC has a strong neuroprotective effect, the clinical application of IPreC for subsequent cerebral ischemia is difficult. There are two main reasons for the above result: Cerebral ischemia is unpredictable, and LIPreC is also capable of inducing unexpected injury with only minor differences to durations or intensity. RIPreC and pharmacological preconditioning, an easy-to-use and non-invasive therapy, can be performed in a variety of clinical settings and appear to be more suitable for the clinical management of ischemic stroke. Hoping to advance our understanding of IPreC, this review mainly focuses on recent advances in IPreC in stroke management, its challenges, and the potential study directions.
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Affiliation(s)
- Yulei Hao
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Meiying Xin
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Liangshu Feng
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Xinyu Wang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Xu Wang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Di Ma
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Jiachun Feng
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
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20
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Spiessberger A, Strange F, Gruter BE, Wanderer S, Casoni D, Gruber P, Diepers M, Remonda L, Fandino J, Añon J, Marbacher S. An endovascular assisted, nonocclusive cerebral bypass: a technical feasibility study in a rabbit model. J Neurosurg 2020; 134:1846-1851. [PMID: 32502997 DOI: 10.3171/2020.3.jns20334] [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: 02/03/2020] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Temporary parent vessel occlusion performed to establish a high-flow interpositional bypass carries the risk of infarcts. The authors investigated the feasibility of a novel technique to establish a high-flow bypass without temporary parent vessel occlusion in order to lower the risk of ischemic complications. METHODS In 10 New Zealand white rabbits, a carotid artery side-to-end anastomosis was performed under parent artery patency with a novel endovascular balloon device. Intraoperative angiography, postoperative neurological assessments, and postoperative MRI/MRA were performed to evaluate the feasibility and safety of the novel technique. RESULTS A patent anastomosis was established in 10 of 10 animals; 3 procedure-related complications occurred. No postoperative focal neurological deficits were observed. The MRI/MRA findings include no infarcts and bypass patency in 50% of the animals. CONCLUSIONS The authors demonstrated the feasibility of an endovascular assisted, nonocclusive high-flow bypass. Future refinement of the device and technique in an animal model is necessary to lower the complication rate and increase patency rates.
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Affiliation(s)
- Alexander Spiessberger
- 1Department of Neurosurgery, Kantonsspital Aarau.,2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Fabio Strange
- 1Department of Neurosurgery, Kantonsspital Aarau.,2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Basil Erwin Gruter
- 1Department of Neurosurgery, Kantonsspital Aarau.,2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Stefan Wanderer
- 1Department of Neurosurgery, Kantonsspital Aarau.,2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Daniela Casoni
- 3Department of Biomedical Research, Faculty of Medicine, University of Bern; and
| | - Philipp Gruber
- 4Division of Neuroradiology, Kantonsspital Aarau, Switzerland
| | - Michael Diepers
- 4Division of Neuroradiology, Kantonsspital Aarau, Switzerland
| | - Luca Remonda
- 4Division of Neuroradiology, Kantonsspital Aarau, Switzerland
| | - Javier Fandino
- 1Department of Neurosurgery, Kantonsspital Aarau.,2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
| | - Javier Añon
- 4Division of Neuroradiology, Kantonsspital Aarau, Switzerland
| | - Serge Marbacher
- 1Department of Neurosurgery, Kantonsspital Aarau.,2Department of Biomedical Research, Cerebrovascular Research Group, University of Bern
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21
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Tecchio F, Cecconi F, Colamartino E, Padalino M, Valci L, Reinert M. The Morphology of Somatosensory Evoked Potentials During Middle Cerebral Artery Aneurysm Clipping (MoSAC): A Pilot Study. Clin EEG Neurosci 2020; 51:130-136. [PMID: 31514539 DOI: 10.1177/1550059419874942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Somatosensory evoked potential (SEP) monitoring is a standard tool during clipping of aneurysms of the middle cerebral artery (MCA), and the parameter used to detect a state of cortical ischemia is amplitude. We think that the sensitivity of SEP can however be improved by using other parameters. Our study moves in this direction via SEP morphology. In this pilot preliminary study, involving a small sample without postoperative neurological deficit, we aimed at investigating the value of SEP morphology (in the 15- to 35-ms time frame), in comparison with SEP amplitude (N20 peak-to-peak), as a measure of sensitivity to blood flow reduction. The changes in the SEP morphology of 16 patients undergoing clipping of an unruptured MCA aneurysm was studied. We applied the Morph-Fréchet index for each recorded SEP (at 30-second intervals), quantifying the pattern shape change with regard to the average SEP recorded after dura opening (baseline). We also compared 3 measurements of the SEP morphology, without and with GARCH-derived filter. Filtered Morph-Fréchet never exceeded the individual's "normality" range in baseline but did so in 81% of the risk phase on average across the 16 subjects, which is more than that for amplitude (36%, P = .002). This pilot study indicates that a measurement derived from the networking nature of the brain was sensitive to blood flow reduction. The SEP morphology approach promises to improve SEP monitoring sensitivity during clipping of unruptured MCA aneurysms. New and Noteworthy. The higher sensitivity to blood flow reduction of SEP morphology than amplitude promises to improve the effectiveness of intraoperative monitoring during MCA aneurysm clipping procedures.
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Affiliation(s)
- Franca Tecchio
- Laboratory of Electrophysiology for Translational neuroScience (LET'S) and Laboratory of Agent Based Social Simulation (LABSS), ISTC, CNR, Rome, Italy
| | - Federico Cecconi
- Laboratory of Electrophysiology for Translational neuroScience (LET'S) and Laboratory of Agent Based Social Simulation (LABSS), ISTC, CNR, Rome, Italy
| | - Elisabetta Colamartino
- Depatment of Neurosurgery, Regional Hospital of Lugano, Neurocentro della Svizzera Italiana (NSI), Lugano, Swiss
| | - Matteo Padalino
- Laboratory of Electrophysiology for Translational neuroScience (LET'S) and Laboratory of Agent Based Social Simulation (LABSS), ISTC, CNR, Rome, Italy
| | - Luca Valci
- Depatment of Neurosurgery, Regional Hospital of Lugano, Neurocentro della Svizzera Italiana (NSI), Lugano, Swiss
| | - Michael Reinert
- Depatment of Neurosurgery, Regional Hospital of Lugano, Neurocentro della Svizzera Italiana (NSI), Lugano, Swiss
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22
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Kameda M, Hishikawa T, Hiramatsu M, Yasuhara T, Kurozumi K, Date I. Precise MEP monitoring with a reduced interval is safe and useful for detecting permissive duration for temporary clipping. Sci Rep 2020; 10:3507. [PMID: 32103082 PMCID: PMC7044220 DOI: 10.1038/s41598-020-60377-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 02/11/2020] [Indexed: 12/14/2022] Open
Abstract
Although temporary clipping of the parent artery is an indispensable technique in clipping surgery for intracranial aneurysms, the permissive duration of temporary clipping is still not well known. The aim of this study is to confirm the safety of precise motor evoked potential (MEP) monitoring and to estimate the permissive duration of temporary clipping for middle cerebral artery (MCA) aneurysm based on precise MEP monitoring results. Under precise MEP monitoring via direct cortical stimulation every 30 seconds to 1 minute, surgeons released a temporary clip and waited for MEP amplitude to recover following severe (>50%) reduction of MEP amplitude during temporary clipping. Precise MEP monitoring was safely performed. Twenty-eight instances of temporary clipping were performed in 42 MCA aneurysm clipping surgeries. Because precise MEP monitoring could be used to determine when to release a temporary clip even with a severe reduction in MEP amplitude due to lengthy temporary clipping, no patients experienced permanent postoperative hemiparesis. Based on logistic regression analysis, if a temporary clip is applied for 312 seconds or more, there is a higher probability of a severe reduction in MEP amplitude. We should therefore release temporary clips after 5 minutes in order to avoid permanent postoperative hemiparesis.
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Affiliation(s)
- Masahiro Kameda
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-Shi, Okayama, 700-8558, Japan.
| | - Tomohito Hishikawa
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-Shi, Okayama, 700-8558, Japan
| | - Masafumi Hiramatsu
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-Shi, Okayama, 700-8558, Japan
| | - Takao Yasuhara
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-Shi, Okayama, 700-8558, Japan
| | - Kazuhiko Kurozumi
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-Shi, Okayama, 700-8558, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama-Shi, Okayama, 700-8558, Japan
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23
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Hausburg MA, Banton KL, Roman PE, Salgado F, Baek P, Waxman MJ, Tanner A, Yoder J, Bar-Or D. Effects of propofol on ischemia-reperfusion and traumatic brain injury. J Crit Care 2019; 56:281-287. [PMID: 32001426 DOI: 10.1016/j.jcrc.2019.12.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/07/2019] [Accepted: 12/24/2019] [Indexed: 12/14/2022]
Abstract
Oxidative stress exacerbates brain damage following ischemia-reperfusion and traumatic brain injury (TBI). Management of TBI and critically ill patients commonly involves use of propofol, a sedation medication that acts as a general anesthetic with inherent antioxidant properties. Here we review available evidence from animal model systems and clinical studies that propofol protects against ischemia-reperfusion injury. However, evidence of propofol toxicity in humans exists and manifests as a rare complication, "propofol infusion syndrome" (PRIS). Evidence in animal models suggests that brain injury induces expression of the p75 neurotrophin receptor (p75NTR), which is associated with proapoptotic signaling. p75NTR-mediated apoptosis of neurons is further exacerbated by propofol's superinduction of p75NTR and concomitant inhibition of neurotrophin processing. Propofol is toxic to neurons but not astrocytes, a type of glial cell. Evidence suggests that propofol protects astrocytes from oxidative stress and stimulates astroglial-mediated protection of neurons. One may speculate that in brain injury patients under sedation/anesthesia, propofol provides brain tissue protection or aids in recovery by enhancing astrocyte function. Nevertheless, our understanding of neurologic recovery versus long-term neurological sequelae leading to neurodegeneration is poor, and it is also conceivable that propofol plays a partial as yet unrecognized role in long-term impairment of the injured brain.
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Affiliation(s)
- Melissa A Hausburg
- Trauma Research Department, Swedish Medical Center, 501 E Hampden, Englewood, CO 80113, USA; Trauma Research Department, St. Anthony Hospital, 11600 W 2nd Pl, Lakewood, CO 80228, USA; Trauma Research Department, Medical City Plano, 3901 W 15th St, Plano, TX 75075, USA; Trauma Research Department, Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO 80907, USA; Trauma Research Department, Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO 64132, USA; Trauma Research Department, Wesley Medical Center, 550 N Hillside St, Wichita, KS 67214, USA
| | - Kaysie L Banton
- Trauma Research Department, Swedish Medical Center, 501 E Hampden, Englewood, CO 80113, USA
| | - Phillip E Roman
- Trauma Research Department, St. Anthony Hospital, 11600 W 2nd Pl, Lakewood, CO 80228, USA; Department of Anesthesiology, St. Anthony Hospital, Lakewood, CO 80228, USA
| | - Fernando Salgado
- Trauma Research Department, Wesley Medical Center, 550 N Hillside St, Wichita, KS 67214, USA; Department of Anesthesiology, Wesley Medical Center, Wichita, KS 67214, USA
| | - Peter Baek
- Trauma Research Department, Medical City Plano, 3901 W 15th St, Plano, TX 75075, USA; Department of Anesthesiology, Medical City Plano, Plano, TX 75075, USA
| | - Michael J Waxman
- Department of Critical Care, Research Medical Center, Kansas City, MO 64132, USA
| | - Allen Tanner
- Trauma Research Department, Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO 80907, USA
| | - Jeffrey Yoder
- Trauma Research Department, St. Anthony Hospital, 11600 W 2nd Pl, Lakewood, CO 80228, USA; Department of Anesthesiology, St. Anthony Hospital, Lakewood, CO 80228, USA
| | - David Bar-Or
- Trauma Research Department, Swedish Medical Center, 501 E Hampden, Englewood, CO 80113, USA; Trauma Research Department, St. Anthony Hospital, 11600 W 2nd Pl, Lakewood, CO 80228, USA; Trauma Research Department, Medical City Plano, 3901 W 15th St, Plano, TX 75075, USA; Trauma Research Department, Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO 80907, USA; Trauma Research Department, Research Medical Center, 2316 E Meyer Blvd, Kansas City, MO 64132, USA; Trauma Research Department, Wesley Medical Center, 550 N Hillside St, Wichita, KS 67214, USA; Department of Molecular Biology, Rocky Vista University, 8401 S Chambers Rd, Parker, CO 80134, USA.
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Intarakhao P, Thiarawat P, Rezai Jahromi B, Kozyrev DA, Teo MK, Choque-Velasquez J, Luostarinen T, Hernesniemi J. Adenosine-induced cardiac arrest as an alternative to temporary clipping during intracranial aneurysm surgery. J Neurosurg 2018; 129:684-690. [DOI: 10.3171/2017.5.jns162469] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVEThe purpose of this study was to analyze the impact of adenosine-induced cardiac arrest (AiCA) on temporary clipping (TC) and the postoperative cerebral infarction rate among patients undergoing intracranial aneurysm surgery.METHODSIn this retrospective matched-cohort study, 65 patients who received adenosine for decompression of aneurysms during microsurgical clipping were identified (Group A) and randomly matched with 65 selected patients who underwent clipping but did not receive adenosine during surgery (Group B). The matching criteria included age, Fisher grade, aneurysm size, rupture status, and location of aneurysms. The primary outcomes were TC time and the postoperative infarction rate. The secondary outcome was the incidence of intraoperative aneurysm rupture (IAR).RESULTSIn Group A, 40 patients underwent clipping with AiCA alone and 25 patients (38%) received AiCA combined with TC, and in Group B, 60 patients (92%) underwent aneurysm clipping under the protection of TC (OR 0.052; 95% CI 0.018–0.147; p < 0.001). Group A required less TC time (2.04 minutes vs 4.46 minutes; p < 0.001). The incidence of postoperative lacunar infarction was equal in both groups (6.2%). There was an insignificant between-group difference in the incidence of IAR (1.5% in Group A vs 6.1% in Group B; OR 0.238; 95% CI 0.026–2.192; p = 0.171).CONCLUSIONSAiCA is a useful technique for microneurosurgical treatment of cerebral aneurysms. AiCA can minimize the use of TC and does not increase the risk of IAR and postoperative infarction.
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Affiliation(s)
- Patcharin Intarakhao
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
- Departments of 2Anesthesiology and
| | - Peeraphong Thiarawat
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
- 3Surgery, Naresuan University, Phitsanulok, Thailand
| | | | - Danil A. Kozyrev
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Mario K. Teo
- 4Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, North Bristol University Hospital, Bristol, United Kingdom; and
| | | | - Teemu Luostarinen
- 5Department of Anesthesiology, Intensive Care, Emergency Care and Pain Clinic, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Hernesniemi
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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Tobalem S, Schutz JS, Chronopoulos A. Central retinal artery occlusion - rethinking retinal survival time. BMC Ophthalmol 2018; 18:101. [PMID: 29669523 PMCID: PMC5907384 DOI: 10.1186/s12886-018-0768-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/03/2018] [Indexed: 01/05/2023] Open
Abstract
Background The critical time from onset of complete occlusion of the central retinal artery (CRA) to functionally significant inner retinal infarction represents a window of opportunity for treatment and also has medical-legal implications, particularly when central retinal artery occlusion (CRAO) complicates therapeutic interventions. Here, we review the evidence for time to infarction from complete CRAO and discuss the implications of our findings. Methods A Medline search was performed using each of the terms “central retinal artery occlusion”, “retinal infarction”, “retinal ischemia”, and “cherry red spot” from 1970 to the present including articles in French and German. All retrieved references as well as their reference lists were screened for relevance. An Internet search using these terms was also performed to look for additional references. Results We find that the experimental evidence showing that inner retinal infarction occurs after 90–240 min of total CRAO, which is the interval generally accepted in the medical literature and practice guidelines, is flawed in important ways. Moreover, the retinal ganglion cells, supplied by the CRA, are part of the central nervous system which undergoes infarction after non-perfusion of 12–15 min or less. Conclusions Retinal infarction is most likely to occur after only 12–15 min of complete CRAO. This helps to explain why therapeutic maneuvers for CRAO are often ineffective. Nevertheless, many CRAOs are incomplete and may benefit from therapy after longer intervals. To try to avoid retinal infarcton from inadvertent ocular compression by a headrest during prone anesthesia, the eyes should be checked at intervals of less than 15′.
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Affiliation(s)
- Stephan Tobalem
- Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
| | - James S Schutz
- Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
| | - Argyrios Chronopoulos
- Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland. .,Department of Ophthalmology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Box 41, Hills Road, Cambridge, CB2 0QQ, UK.
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26
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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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27
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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 2017; 129:84-90. [PMID: 28946178 DOI: 10.3171/2017.3.jns162505] [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] [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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van Doormaal TPC, Diederen SJH, van der Zwan A, Berkelbach JW, Kropveld A, Depauw PRAM. Simulating Internal Carotid Artery Injury during Transsphenoidal Transclival Endoscopic Surgery in a Perfused Cadaver Model. J Neurol Surg B Skull Base 2017; 79:161-166. [PMID: 29868321 DOI: 10.1055/s-0037-1605594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 07/08/2017] [Indexed: 10/19/2022] Open
Abstract
Introduction Managing internal carotid artery (ICA) injury during extended endoscopic transsphenoidal surgery is an extreme challenge. We aimed to find a possible surgical treatment strategy. Methods We operated seven fresh, perfused cadaver heads with a transsphenoidal endoscopic approach of the ICA using a three-dimensional-high definition (3D-HD) endoscope. We made a paraclival ICA leak, which we tried to manage with clips and microsutures. Results Accurate transsphenoidal clip application on the ICA was impossible with standard aneurysm clips and applier. It was only feasible with a 9 mm slightly bended clip that could be opened from the inside and be applied with a dedicated flexible thin applier. Transsphenoidal suturing of an ICA leak was impossible from the ipsilateral nostril or with standard microinstruments. Suturing was only feasible from the contralateral nostril using flexible microinstruments with a thin 90-mm shaft. This was technically very challenging and involved a steep learning curve. Conclusion Tamponade with muscle or fat and a quick transfer to the angiography suite for endovascular control remains the preferable option in case of an ICA leak during endoscopic transsphenoidal surgery. If tamponade gives insufficient initial control, ICA clipping could be possible with dedicated instruments, with risk of increasing the defect, stenosis, or occlusion of the vessel. Transsphenoidal ICA suturing remains extremely difficult, and laboratory practice seems essential.
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Affiliation(s)
- Tristan P C van Doormaal
- Department of Neurosurgery, University Medical Center Utrecht, Brain Center Rudolph Magnus, Utrecht, The Netherlands.,Brain Technology Institute, Utrecht, The Netherlands
| | - Sander J H Diederen
- Department of Neurosurgery, University Medical Center Utrecht, Brain Center Rudolph Magnus, Utrecht, The Netherlands.,Brain Technology Institute, Utrecht, The Netherlands
| | - Albert van der Zwan
- Department of Neurosurgery, University Medical Center Utrecht, Brain Center Rudolph Magnus, Utrecht, The Netherlands.,Brain Technology Institute, Utrecht, The Netherlands
| | - Jan Willem Berkelbach
- Department of Neurosurgery, University Medical Center Utrecht, Brain Center Rudolph Magnus, Utrecht, The Netherlands
| | - Arvid Kropveld
- Department of Neurosurgery, St. Elisabeth Hospital, Tilburg, The Netherlands
| | - Paul R A M Depauw
- Department of Neurosurgery, St. Elisabeth Hospital, Tilburg, The Netherlands
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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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Tanabe J, Ishikawa T, Moroi J. Safe time duration for temporary middle cerebral artery occlusion in aneurysm surgery based on motor-evoked potential monitoring. Surg Neurol Int 2017; 8:79. [PMID: 28584682 PMCID: PMC5445649 DOI: 10.4103/sni.sni_410_16] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 03/20/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Temporary vessel occlusion of the parent artery is an essential technique for aneurysm surgery. Our aim was to clarify the safe time for temporary occlusion for aneurysm surgery, that is the "safe time duration" (STD), in which brain tissue exposed to ischemia will almost never fall into even the ischemic penumbra during temporary occlusion of the middle cerebral artery (MCA), and even transient postoperative motor impairment will be rare using intraoperative motor-evoked potentials (MEP). METHODS Twenty-four patients underwent MCA aneurysm clipping surgery with MEP monitoring for 13 ruptured aneurysms and 11 unruptured aneurysms. The duration of vessel occlusion in patients without MEP changes was measured as the STD. Average STD was calculated as 95% confidence interval for the population mean using sample data from patients with MEP changes and patients without changes. RESULTS All 24 patients received proximal flow control only. Five patients (20.8%) developed significant intraoperative MEP changes. Time to MEP change (i.e., STD) in these patients was 4.6 ± 2.1 min. In patients without MEP changes, STD was 2.7 ± 1.4 min. Average STD was thus 3.1 ± 0.7 min. CONCLUSIONS The 95% lower confidence limit for average STD was 2.4 min when applying temporary occlusion on the proximal side of the MCA. This STD resembled that previously reported for temporary proximal occlusion of the internal carotid artery.
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Affiliation(s)
- Jun Tanabe
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
| | - Junta Moroi
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan
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31
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Russin JJ. The arborization bypass: Sequential intracranial-intracranial bypasses for an unruptured fusiform MCA aneurysm. J Clin Neurosci 2017; 39:209-211. [PMID: 28209313 DOI: 10.1016/j.jocn.2017.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/22/2017] [Indexed: 10/20/2022]
Abstract
Revascularization techniques are being featured more prominently as endovascular treatments continue to select out complex cerebrovascular pathologies for open surgical management. The current healthcare environment requires decreased hospital stays and improved clinical outcomes despite the growing complexity of open surgical cases. Recent efforts to reduce operative room time and decrease risk for bypass surgery have focused on avoiding graft harvest and maintaining the entire bypass intracranial. The presented technique features an arborization bypass to serially anastomose the middle cerebral artery vessels allowing for proximal trapping of a complex aneurysm without graft harvest. The arborization technique has several advantages to traditional techniques and serves to supplement the revascularization surgeon's armamentarium.
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Affiliation(s)
- Jonathan J Russin
- University of Southern California Neurorestoration Center, Department of Neurological Surgery, The Keck School of Medicine, Los Angeles, CA, USA.
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32
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Spina A, Mortini P. Intraoperative Neuromonitoring Strategies for Temporary Clipping in Aneurysm Surgery. World Neurosurg 2017; 101:773-775. [PMID: 28189866 DOI: 10.1016/j.wneu.2017.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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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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Thirumala PD, Udesh R, Muralidharan A, Thiagarajan K, Crammond DJ, Chang YF, Balzer JR. Diagnostic Value of Somatosensory-Evoked Potential Monitoring During Cerebral Aneurysm Clipping: A Systematic Review. World Neurosurg 2016; 89:672-80. [DOI: 10.1016/j.wneu.2015.12.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/10/2015] [Accepted: 12/12/2015] [Indexed: 10/22/2022]
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35
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Eliava S, Pilipenko Y, Shekhtman O, Konovalov A. Reversal of intraoperative arterial thrombosis with a fibrinolytic agent when treating large and giant partially thrombosed aneurysms of the middle cerebral artery. J Neurosurg 2016; 124:1114-22. [DOI: 10.3171/2015.2.jns142655] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Thrombosis of the cerebral arteries is one of the complications of microsurgical operations for partially thrombosed intracranial aneurysms. The object of this study was to assess the frequency of intraoperative arterial thrombosis (IAT) during microsurgical treatment of large and giant partially thrombosed aneurysms of the middle cerebral artery (MCA) and also to assess the efficacy of the treatment of this complication.
MATERIALS
The authors analyzed a consecutive series of 53 patients who underwent surgery for partially thrombosed aneurysms of the MCA at the Burdenko Neurosurgical Institute between January 2005 and September 2014. Thirty-two patients had large aneurysms (15–25 mm) and 21 had giant aneurysms (> 25 mm). Clipping of aneurysms was performed in 47 patients, trapping was performed in 3, and wrapping was performed in 3.
RESULTS
IAT was diagnosed in 10 patients (18.9%). The authors describe a technique for IAT reversal involving the injection of modified human recombinant prourokinase (mr-proUK). Of the 7 patients who underwent injection of mr-proUK in the thrombosed artery, 5 (71.4%) were discharged without any change in neurological status, 1 (14.3%) experienced moderate deterioration (modified Rankin Scale [mRS] score of 2), and 1 (14.3%) experienced severe deterioration (mRS score of 4). Among the 3 patients who had complications and did not receive an injection of mr-proUK, 2 experienced severe deterioration (mRS score of 3 and 4) and 1 had moderate deterioration (mRS score of 2).
CONCLUSIONS
The primary risk factor of thrombectomy with temporary trapping is thrombosis in the MCA branches. The injection of a fibrinolytic agent into thrombosed MCA branches is an effective method for the treatment of IAT.
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"Clip first" policy in management of intracranial MCA aneurysms: Single-centre experience with a systematic review of literature. Acta Neurochir (Wien) 2016; 158:533-46; discussion 546. [PMID: 26733126 DOI: 10.1007/s00701-015-2687-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 12/17/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND The results of microsurgical treatment for middle cerebral artery (MCA) aneurysms (ANs) have been highly satisfying for decades, notoriously posing a challenge for interventional neuroradiologists. Following the International Subarachnoid Aneurysm Trial (ISAT) study results, most centres across Europe and the USA switched to a "coil first" policy. The purpose of this study is to evaluate and critically review the substantiation of this change. METHODS The authors conducted a single-institution retrospective study of MCA AN treatment between January 2000 and December 2013 maintaining a "clip first" policy. The results are supplied with a literature review. RESULTS A total of 315 MCA ANs were treated in 288 consecutive patients (209 females, 79 males). Microsurgical treatment was performed for 238 AN patients (116 ruptured, 122 unruptured) and 77 AN patients (46 ruptured, 31 unruptured) who underwent a coiling procedure. Treatment-related morbidity and mortality (MM) for unruptured ANs was 2.8 % in the microsurgical group and 10.3 % in the endovascular group. The percentage of patients with no/minor permanent neurological deficits after SAH in a good initial clinical state (HH 1-2) was 93 % in the microsurgical and 76 % in the endovascular group. A literature review identified 21 studies concerning MCA AN treatment with a specified decision-making algorithm. Microsurgery seemed superior to endovascular management regarding both clinical and radiological outcomes, although several aspects of the analysed reports might appear questionable. CONCLUSION Although this study has its inherent limitations, the effect brought about by microsurgical clipping of MCA ANs remains superior to that of endovascular embolisation and it should be sustained as the first treatment choice. The decision about the treatment strategy should be made by a multi-disciplinary team consisting of specialists from both teams, bearing in mind the higher occlusion rate and longevity of the surgical treatment.
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Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a worldwide health burden with high fatality and permanent disability rates. The overall prognosis depends on the volume of the initial bleed, rebleeding, and degree of delayed cerebral ischemia (DCI). Cardiac manifestations and neurogenic pulmonary edema indicate the severity of SAH. The International Subarachnoid Aneurysm Trial (ISAT) reported a favorable neurological outcome with the endovascular coiling procedure compared with surgical clipping at the end of 1 year. The ISAT trial recruits were primarily neurologically good grade patients with smaller anterior circulation aneurysms, and therefore the results cannot be reliably extrapolated to larger aneurysms, posterior circulation aneurysms, patients presenting with complex aneurysm morphology, and poor neurological grades. The role of hypothermia is not proven to be neuroprotective according to a large randomized controlled trial, Intraoperative Hypothermia for Aneurysms Surgery Trial (IHAST II), which recruited patients with good neurological grades. Patients in this trial were subjected to slow cooling and inadequate cooling time and were rewarmed rapidly. This methodology would have reduced the beneficial effects of hypothermia. Adenosine is found to be beneficial for transient induced hypotension in 2 retrospective analyses, without increasing the risk for cardiac and neurological morbidity. The neurological benefit of pharmacological neuroprotection and neuromonitoring is not proven in patients undergoing clipping of aneurysms. DCI is an important cause of morbidity and mortality following SAH, and the pathophysiology is likely multifactorial and not yet understood. At present, oral nimodipine has an established role in the management of DCI, along with maintenance of euvolemia and induced hypertension. Following SAH, hypernatremia, although less common than hyponatremia, is a predictor of poor neurological outcome.
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Affiliation(s)
- Stanlies D'Souza
- Department of Neuroanesthesiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA
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Thines L, Proust F, Marinho P, Durand A, van der Zwan A, Regli L, Lejeune JP. Giant and complex aneurysms treatment with preservation of flow via bypass technique. Neurochirurgie 2015; 62:1-13. [PMID: 26072226 DOI: 10.1016/j.neuchi.2015.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 02/02/2015] [Accepted: 03/01/2015] [Indexed: 10/23/2022]
Abstract
Due to their anatomical characteristics and the complexity of the procedures required to obtain their complete occlusion, the treatment of giant intracranial aneurysms is a real challenge. Direct reconstructive strategies, whether by interventional neuroradiology (coils, stents) or microsurgical (clipping) means, are not always applicable and, in patients that would not tolerate parent or collateral artery sacrifice, the adjunction of a revascularization procedure using a bypass technique might be necessary. Cerebral arterial bypasses can be classified according to their function (3 types: flow replacement, flow reversal or protective), the branching mode of the graft used (3 types: pedicled, interpositional or in situ), the sites of anastomosis (2 types: extracranial-intracranial or intracranial-intracranial) and the class of flow they are supposed to provide (3 types: low-, intermediate- or high-flow). In this article, the authors review the different aspects in the management of patients with a giant intracranial aneurysm using a bypass: preoperative work-up, types of bypass and indications, surgical techniques and results.
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Affiliation(s)
- L Thines
- Clinique de neurochirurgie, Pôle des neurosciences et appareil locomoteur, CHRU de Lille, Université Lille Nord de France, 59000 Lille, France.
| | - F Proust
- Service de neurochirurgie, Hôpital Charles-Nicolle, CHU de Rouen, 76038 Rouen, France
| | - P Marinho
- Clinique de neurochirurgie, Pôle des neurosciences et appareil locomoteur, CHRU de Lille, Université Lille Nord de France, 59000 Lille, France
| | - A Durand
- Clinique du Tonkin, 69626 Villeurbanne cedex, France
| | - A van der Zwan
- Department of Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - J-P Lejeune
- Clinique de neurochirurgie, Pôle des neurosciences et appareil locomoteur, CHRU de Lille, Université Lille Nord de France, 59000 Lille, France
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Chi OZ, Barsoum S, Rah KH, Liu X, Weiss HR. Local O2 Balance in Cerebral Ischemia-Reperfusion Improved during Pentobarbital Compared with Isoflurane Anesthesia. J Stroke Cerebrovasc Dis 2015; 24:1196-203. [PMID: 25869775 DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 12/15/2014] [Accepted: 01/08/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Most anesthetics affect cerebral blood flow and metabolism. We compared microregional O2 balance in cerebral ischemia-reperfusion during pentobarbital and isoflurane anesthesia. METHODS After 1 hour of middle cerebral artery occlusion and a 2-hour reperfusion under isoflurane (1.4%, n = 14) or pentobarbital (50 mg/kg, n = 14) anesthesia in rats, regional cerebral blood flow using (14)C-iodoantipyrine autoradiography, microregional arterial and venous O2 saturation (20-60 μm in diameter) using cryomicrospectrophotometry, and the size of cortical infarct were determined. RESULTS Ischemia-reperfusion decreased the average cortical venous O2 saturation in both pentobarbital and isoflurane groups (P < .0001), which was higher (P < .05) with pentobarbital despite a similar average regional cerebral blood flow and O2 consumption. The heterogeneity of venous O2 saturation reported as a coefficient of variation (100 × standard deviation/mean) was smaller (P < .005) with pentobarbital than that with isoflurane (7.5 versus 16.1). The number of veins with low venous O2 saturation (<50%) was smaller (P < .005) with pentobarbital (5 of 80 versus 24 of 80). The percentage of cortical infarct in total cortex was smaller with pentobarbital (5.2 ± 2.5% versus 12.3 ± 2.6%, P < .001). CONCLUSIONS In the cerebral ischemic-reperfused cortex, the average venous O2 saturation was higher, and its heterogeneity and the number of veins with low O2 saturation were smaller under pentobarbital than isoflurane anesthesia. This improvement in microregional O2 balance with pentobarbital was accompanied by the reduced cortical infarct. Our data suggest that the neurologic outcome could vary during cerebral ischemia-reperfusion depending on the anesthetics used.
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Affiliation(s)
- Oak Z Chi
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
| | - Sylviana Barsoum
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kang H Rah
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Xia Liu
- Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Harvey R Weiss
- Department of Neuroscience and Cell Biology, Robert Wood Johnson Medical School, Piscataway, New Jersey
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Anesthesia for the surgical treatment of cerebral aneurysms☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543001-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Anestesia para el tratamiento quirúrgico de aneurismas cerebrales. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2014.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Lecours M, Gelb AW. Anesthesia for the surgical treatment of cerebral aneurysms. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Ratilal BO, Rocha JPF, Fernandes AMA, Arroja MMC, Barateiro AP, Brites DMTO, Pinto RMA, Sepodes BMN, Mota-Filipe HD. TDZD-8 pre-treatment in transient middle cerebral artery occlusion. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.biomag.2014.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Durga P, Kinthala S, Sahu BP, Panigrahi MK, Mantha S, Ramachandran G. Efficacy and outcomes of perioperative anesthetic management of extracranial to intracranial bypass for complex intracranial aneurysm in the absence of advanced neurological monitoring. J Anaesthesiol Clin Pharmacol 2014; 30:345-50. [PMID: 25190941 PMCID: PMC4152673 DOI: 10.4103/0970-9185.137265] [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] [Indexed: 11/20/2022] Open
Abstract
Background and Aims: Anesthetic management of extracranial to intracranial (EC-IC) bypass for complex intracranial aneurysms is challenging as the goals involve balancing the cerebral perfusion during parent artery clamping and avoiding factors that predispose to rupture of the unsecured aneurysm. There is very sparse literature available on anesthetic management for this procedure. Materials and Methods: A retrospective review of the records of 20 patients undergoing EC-IC bypass was performed with an objective of assessing the efficacy and outcomes of anesthetic management in the absence of advanced neurological monitoring. Results: A total of 20 patients underwent EC-IC bypass as an adjunct cerebral revascularization in the management of complex intracranial aneurysms. Intraoperatively normotension and normocarbia were maintained. During the EC-IC bypass, when the temporary clamp was applied, mild hypertension (increase from baseline by 20%) and hypervolemia (central venous pressure increased to 12 mmHg) were maintained. Cerebral protection during temporary clipping of intracranial vessel was provided using moderate hypothermia to 34°C and intravenous thiopentone. Temporary clip time ranged from 15 min to 54 min (mean-25 min). All patients except one were extubated post-operatively (19/20 = 95%). None of the patients had rupture of aneurysm in the peri-operative period. Three patients developed neurologic events (3/20 = 15%). One patient had cerebral vasospasm and two patients developed cerebral infarction. Two patient subsequently improved and one succumbed to the neurological deterioration (mortality 1/20 = 5%). Conclusion: Adherence to the principal goals for the procedure, avoidance of hemodynamic fluctuations such as hypotension and hypertension, maintenance of normocarbia, and cerebral protection, result in favorable neurological outcome even in the absence of advanced neuromonitoring.
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Affiliation(s)
- Padmaja Durga
- Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Sudhakar Kinthala
- Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Barada Prasad Sahu
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Manas Kumar Panigrahi
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Srinivas Mantha
- Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
| | - Gopinath Ramachandran
- Departments of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
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Chiao S, Zuo Z. A double-edged sword: volatile anesthetic effects on the neonatal brain. Brain Sci 2014; 4:273-94. [PMID: 24961761 PMCID: PMC4101477 DOI: 10.3390/brainsci4020273] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/28/2014] [Accepted: 03/31/2014] [Indexed: 02/01/2023] Open
Abstract
The use of volatile anesthetics, a group of general anesthetics, is an exceedingly common practice. These anesthetics may have neuroprotective effects. Over the last decade, anesthetic induced neurotoxicity in pediatric populations has gained a certain notoriety based on pre-clinical cell and animal studies demonstrating that general anesthetics may induce neurotoxicity, including neuroapoptosis, neurodegeneration, and long-term neurocognitive and behavioral deficits. With hundreds of millions of people having surgery under general anesthesia worldwide, and roughly six million children annually in the U.S. alone, the importance of clearly defining toxic or protective effects of general anesthetics cannot be overstated. Yet, with our expanding body of knowledge, we have come to learn that perhaps not all volatile anesthetics have the same pharmacological profiles; certain ones may have a more favorable neurotoxic profile and may actually exhibit neuroprotection in specific populations and situations. Thus far, very few clinical studies exist, and have not yet been convincing enough to alter our practice. This review will provide an update on current data regarding volatile anesthetic induced neurotoxicity and neuroprotection in neonatal and infant populations. In addition, this paper will discuss ongoing studies and the trajectory of further research over the coming years.
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Affiliation(s)
- Sunny Chiao
- Department of Anesthesiology, University of Virginia, Charlottesville, VA 22908, USA.
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia, Charlottesville, VA 22908, USA.
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Abstract
Preconditioning (PC) describes a phenomenon whereby a sub-injury inducing stress can protect against a later injurious stress. Great strides have been made in identifying the mechanisms of PC-induced protection in animal models of brain injury. While these may help elucidate potential therapeutic targets, there are questions over the clinical utility of cerebral PC, primarily because of questions over the need to give the PC stimulus prior to the injury, narrow therapeutic windows and safety. The object of this review is to address the question of whether there may indeed be a clinical use for cerebral PC and to discuss the deficiencies in our knowledge of PC that may hamper such clinical translation.
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Adenosine-Induced Flow Arrest to Facilitate Intracranial Aneurysm Clip Ligation Does Not Worsen Neurologic Outcome. Anesth Analg 2013; 117:1205-10. [DOI: 10.1213/ane.0b013e3182a6d31b] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Park HW, Chung SY, Park MS, Kim SM, Yoon BH, Kim HK. Two indices affecting the directions of the sylvian fissure dissection in middle cerebral artery bifurcation aneurysms. J Cerebrovasc Endovasc Neurosurg 2013; 15:164-70. [PMID: 24167795 PMCID: PMC3804653 DOI: 10.7461/jcen.2013.15.3.164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 08/05/2013] [Accepted: 08/08/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study proposes more objective methods for deciding the appropriate direction of the sylvian fissure dissection during surgical clipping in middle cerebral artery (MCA) bifurcation aneurysms. METHODS We reviewed data of 36 consecutive patients with MCA bifurcation aneurysms. We measured 2 indices preoperatively on 3-dimensional computed tomography angiography (3D-CTA). Analysis of the calculated data allowed us to select the appropriate direction of sylvian fissure dissection for ease of proximal control of M1. Statistically, Mann-Whitney test was used. RESULTS We classified subjects into 2 groups based on the technical level of M1 exposure during surgical clipping. When it was difficult to expose M1, subjects were assigned to Group I, and Group II were subjects in whom M1 exposure was easy. The mean difference between the distances extending from the limbus sphenoidale (LS) line to the internal carotid artery bifurcation and extending from the LS line to the MCA bifurcation was 1.00 ± 0.42 mm in group I and 4.39 ± 2.14 mm in group II. The mean M1 angle was 9.36 ± 3.73° in the group I and 34.05 ± 16.71° in the group II (M1 slope gap p < 0.05, M1 angle p < 0.05). CONCLUSION We have found an objective method for preoperatively verifying ease of exposure of M1 artery during surgical clipping. Therefore, we suggest use of the preoperative M1 slope gap and M1 angle as indicators in 3D-CTA selecting the direction of sylvian fissure dissection for easy proximal control of M1.
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Affiliation(s)
- Hyun Wook Park
- Department of Neurosurgery, Eulji University Hospital, College of Medicine, Eulji University, Taejon, Korea
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Bohnstedt BN, Kemp WJ, Li Y, Payner TD, Horner TG, Leipzig TJ, Cohen-Gadol AA. Surgical Treatment of 127 Anterior Choroidal Artery Aneurysms A Cohort Study of Resultant Ischemic Complications. Neurosurgery 2013; 73:933-9; discussion 939-40. [PMID: 23921702 DOI: 10.1227/neu.0000000000000131] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The anterior choroidal artery (AChA) supplies important areas of the nervous system, particularly the posterior limb of the internal capsule and optic radiation. Treatment of AChA aneurysms poses particular challenges because of the complex anatomy of the aneurysm associated with the relatively small diameter of AChAs, making preservation of the parent vessel during clip ligation or endosaccular coiling challenging.
OBJECTIVE:
To investigate the incidence and features of ischemia in treatment of AChA aneurysms.
METHODS:
A prospectively maintained database of patients who underwent treatment of aneurysms from 1985 to 2011 was queried to find patients with AChA aneurysms. Age, sex, Hunt and Hess grade, treatment modality, and complications were analyzed by use of the unpaired Student t test and Fisher exact test.
RESULTS:
One hundred twenty-two patients harbored 127 AChA aneurysms, and 67% (82 of 122) had multiple aneurysms. Treatment included 112 microsurgical clip ligations, 8 endosaccular coil embolizations, 5 aneurysmal wrappings, and 2 surgical explorations. Complications developed in 53% (67 of 127) of AChA aneurysms. Postoperative ischemia occurred in 12% (15 of 127) of treated aneurysms. The number of temporary clip applications was most closely associated with postoperative ischemia. Glasgow Outcome Scale scores of 4 or 5 were obtained by 78% at discharge, 89% at 6 months, and 85% at 1 year.
CONCLUSION:
The ischemic complication rate from surgical treatment of AChA aneurysms is most closely associated with higher frequency of temporary clip applications for proximal control and may be lower than previously reported. Supplementary intraoperative tools and limitation of vessel manipulation should be used to improve outcomes.
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Affiliation(s)
- Bradley N. Bohnstedt
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - William J. Kemp
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yiping Li
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Troy D. Payner
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Terry G. Horner
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas J. Leipzig
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Aaron A. Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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MURAI Y, MIZUNARI T, KOBAYASHI S, UMEOKA K, TATEYAMA K, KOKETSU K, MATANO F, KITAMURA T, TERAMOTO A. Basic Techniques of Radial Artery Graft to Prevent Surgical Complications. ACTA ACUST UNITED AC 2013. [DOI: 10.2335/scs.41.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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