Results of re-exploration because of compromised distal blood flow after clipping unruptured intracranial aneurysms

Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020

BACKGROUND

The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time.

METHODS

A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests.

RESULTS

A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987.

CONCLUSIONS

The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.

Evaluation of multimodal intraoperative neurophysiologic monitoring during supratentorial aneurysm surgery: a comparative study

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.

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

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

Anaphylactic Shock After Indocyanine Green Video Angiography During Cerebrovascular Surgery

BACKGROUND

Indocyanine green (ICG) video angiography has been widely used in cerebrovascular surgery. ICG injection is generally safe, with a low incidence of complications. ICG-related anaphylactic reactions during neurosurgery have been rarely reported. We report the cases of 2 patients who had experienced anaphylactic shock in response to intravenous ICG injection (DID Indocyanine Green [Dongindang, Inc., Gyeonggi-do, Republic of Korea]) during intracranial aneurysm (IA) surgery.

CASE DESCRIPTION

The first patient, a 69-year-old woman with an unruptured IA, had been undergoing clipping surgery under general anesthesia. Immediately after ICG injection, her blood pressure suddenly decreased from 140/80 mm Hg to 50/30 mm Hg and she developed a skin rash on her abdomen and all extremities. Chest compression was initiated, and her vital signs gradually recovered to their pre-ICG levels within 10 minutes. The second patient was a 58-year-old woman with an unruptured IA who had been undergoing clipping surgery. After ICG injection, her blood pressure had decreased from 130/80 mm Hg to 60/40 mm Hg, and a rash-like skin lesion was observed on her abdomen. After intravenous injection of norepinephrine and dexamethasone, her blood pressure recovered to its pre-ICG level within 30 minutes and remained stable thereafter. The postoperative ICG skin provocation test findings were positive for both patients; however, only 1 patient showed markedly increased serum tryptase levels.

CONCLUSION

Despite the rarity of ICG-related anaphylaxis, clinicians should be aware of this unexpected, but potentially life-threatening, drug reaction in patients undergoing cerebrovascular surgery.

Intraoperative use of transcranial motor/sensory evoked potential monitoring in the clipping of intracranial aneurysms: evaluation of false-positive and false-negative cases

OBJECTIVE

Somatosensory and motor evoked potentials (SEPs and MEPs) are often used to prevent ischemic complications during aneurysm surgeries. However, surgeons often encounter cases with suspicious false-positive and false-negative results from intraoperative evoked potential (EP) monitoring, but the incidence and possible causes for these results are not well established. The aim of this study was to investigate the efficacy and reliability of EP monitoring in the microsurgical treatment of intracranial aneurysms by evaluating false-positive and false-negative cases.

METHODS

From January 2012 to April 2016, 1514 patients underwent surgery for unruptured intracranial aneurysms (UIAs) with EP monitoring at the authors' institution. An EP amplitude decrease of 50% or greater compared with the baseline amplitude was defined as a significant EP change. Correlations between immediate postoperative motor weakness and EP monitoring results were retrospectively reviewed. The authors calculated the sensitivity, specificity, and positive and negative predictive values of intraoperative MEP monitoring, as well as the incidence of false-positive and false-negative results.

RESULTS

Eighteen (1.19%) of the 1514 patients had a symptomatic infarction, and 4 (0.26%) had a symptomatic hemorrhage. A total of 15 patients showed motor weakness, with the weakness detected on the immediate postoperative motor function test in 10 of these cases. Fifteen false-positive cases (0.99%) and 8 false-negative cases (0.53%) were reported. Therefore, MEP during UIA surgery resulted in a sensitivity of 0.10, specificity of 0.94, positive predictive value of 0.01, and negative predictive value of 0.99.

CONCLUSIONS

Intraoperative EP monitoring has high specificity and negative predictive value. Both false-positive and false-negative findings were present. However, it is likely that a more meticulously designed protocol will make EP monitoring a better surrogate indicator of possible ischemic neurological deficits.

Delayed Branching Artery Occlusion Caused by Clip Rotation after Intracranial Aneurysm Clippings

Clip rotation after clipping is a major cause of delayed cerebral ischemia and may occur after any of several intraoperative monitoring techniques. We experienced 3 cases of clip rotation in 3 patients after clipping between March 2011 and December 2013. One of these patients has permanent motor weakness of the left upper extremity because of delayed occlusion of the right M1 lenticulostriate artery. The other two developed delayed occlusion of the frontopolar artery or of the A1 perforating artery, but did not have any neurologic deficits. Clinicians need to exercise great care not to compromise distal blood flow after clipping intracranial aneurysms. We present 3 cases in which clip rotation occurred after aneurysm clipping and progressively compromised blood flow of a nearby branching artery.

Analysis of Unplanned Return to the Operating Room Within 30 Days of Initial Neurosurgery: A 3-Year Experience at a Single Center

OBJECTIVE

The goal of this study was to evaluate the reasons and prognosis of unplanned return to the operating room (URTOR) and to help improve neurosurgical service quality.

METHODS

Medical records of URTOR within 30 days of initial surgery were reviewed at a single neurosurgical center for a period of 3 years. Out of 4516 neurosurgeries, 62 URTOR cases were included to analyze patients' age, sex, initial surgery code, seniority of the performed surgeon, interval between the reopening procedures and initial procedures, reason for reopening, prognosis, and complications.

RESULTS

The 62 patients underwent 70 URTORs. Out of 1445 primary operations performed by junior surgeons, 40 experienced URTOR, whereas 22 of 3071 craniotomies initially performed by senior surgeons resulted in URTOR. Five patients died in this series. Out of the 54 patients who experienced 1-time URTOR, 3 died, whereas 2 of the 8 patients who experienced 2-time URTOR died. Of 22 URTOR surgeries performed by senior surgeons, 10 took place within 24 hours, compared with 26 out of 48 performed by the junior surgeon.

CONCLUSIONS

The main reasons for URTOR after neurosurgery were rebleeding and swelling of the brain. The number of URTORs and time from primary craniotomy to URTOR are not associated with morbidity or mortality. However, the seniority of the surgeon affects the rate of URTOR: surgeons with rich experience in surgery may reduce the chance of a second craniotomy and increase the chance of a good prognosis.

Effectiveness and Limitations of Intraoperative Monitoring with Combined Motor and Somatosensory Evoked Potentials During Surgical Clipping of Unruptured Intracranial Aneurysms

OBJECTIVE

Postoperative neurologic deficits are one of the devastating complications that can result from surgical clipping of unruptured intracranial aneurysms. Intraoperative monitoring (IOM) of motor and somatosensory evoked potentials (EPs) has been used to reduce neurologic sequelae. We evaluated the effectiveness and limitations of IOM in prevention of surgical complications during aneurysm clipping.

METHODS

A retrospective analysis was performed, involving 386 operations for 429 unruptured intracranial aneurysms in 386 patients with consecutively collected IOM data.

RESULTS

Significant EP changes were detected during clipping of 23 aneurysms in 23 patients (5.4% of aneurysms). Among them, 8 patients (accounting for 2.1% of operations and 1.9% of aneurysms) experienced postoperative motor deficits, including 3 permanent and 5 temporary motor deficits with corresponding radiologic lesions. In detecting postoperative motor deficits, the sensitivity and specificity of motor EP monitoring were 0.38 and 0.99, respectively, and those of somatosensory EP monitoring were 0.25 and 0.96, respectively. Seven patients (1.8% of operations) with unchanged EPs had other kinds of postoperative neurologic complications, including altered mentality in 5 cases, motor aphasia in 1, and gaze limitation in 1, with corresponding radiologic abnormalities. However, all 7 patients with other neurologic symptoms recovered within 6 months after surgery.

CONCLUSIONS

IOM of motor and somatosensory EPs was useful and reliable in predicting and preventing postoperative motor deficits. However, it also showed some limitations in the significance of positive EP changes and detection of neurologic deficits other than motor function.

Treatment of Large and Giant Middle Cerebral Artery Aneurysms: Risk Factors for Unfavorable Outcomes

OBJECTIVE

This study aimed to assess the clinical and radiologic outcomes after neurosurgical treatment of large and giant aneurysms of the middle cerebral artery (MCA). In addition, we aimed to identify risk factors for unfavorable outcomes.

METHODS

This retrospective study included 105 patients with 106 large or giant MCA aneurysms treated with neurosurgical methods, including microsurgery and endovascular treatment, over a 15-year period.

RESULTS

The mean aneurysm size was 15.3 ± 7.1 mm. Ten (9.4%) were giant aneurysms. The MCA bifurcation was the most common aneurysm site, followed by the MCA trunk and distal MCA. Aneurysm clipping was the most common treatment method, followed by clipping or trapping with bypass surgery and endovascular treatment. However, acute cerebral infarction was the most common complication (16.0%), poor outcomes (modified Rankin Scale score, 3-6) developed in 12.3% of aneurysms after treatment, and 6.6% of treated aneurysms needed retreatment. Multivariate analysis showed that independent risk factors for acute cerebral infarction after treatment were aneurysms located on the MCA trunk and 2 or more underlying diseases. Initial presentation with subarachnoid hemorrhage and complications during treatment were independent risk factors for poor outcomes. In addition, endosaccular coiling was an independent risk factor for retreatment.

CONCLUSIONS

Neurosurgical management should be considered a priority for large and giant MCA aneurysms because of the high rupture rate and clinical symptoms. However, treatment outcomes remain unsatisfactory. Therefore, tailored management with consideration of risk factors for unfavorable outcomes should be implemented.