Intra-operative cerebral blood flow assessment by indocyanine green video-angiography after temporary arterial occlusion in aneurysm surgery and its clinical implications: a prospective study

Intraoperative neuromonitoring as an independent predictor for postoperative delirium in ICU following aneurysm clipping

Objectives

This study aims to evaluate the diagnostic accuracy of significant intraoperative neurophysiological monitoring (IONM) changes as an independent predictor of postoperative delirium (POD) in patients undergoing aneurysm clipping.

Methods

IONM and clinical data from 273 patients who underwent craniotomy for aneurysm clipping from 2019 until 2021 were retrospectively reviewed. Significant IONM changes and POD were respectively evaluated based on visual review of data and clinical documentation. POD was assessed multiple times in the ICU using the Intensive Care Delirium Screening Checklist (ICDSC).

Results

Of the 273 patients undergoing craniotomy with IONM, 83 had POD (30.4 %). Significant IONM changes were noted in 42 patients, of which 19 patients had POD (45.2 %). In contrast, 231 patients had no IONM changes during surgery, of which 64 (27.7 %) patients had POD. Multivariable analysis showed that significant IONM changes were associated with POD, OR: 2.09 (95 % CI 1.01-4.43, p-value: 0.046). Additionally, somatosensory evoked potentials (SSEP) changes were significantly associated with POD (p-value: 0.044).

Conclusion

Significant IONM changes are associated with an increased risk of POD in patients undergoing craniotomy for aneurysm clipping. Our findings offer a strong basis for future research and analysis of EEG and SSEP monitoring to detect and possibly prevent POD.

Utilizing indocyanine green video angiography to bridge intracranial aneurysm treatment gaps in low- and middle-income countries: a mini-review

Intracranial aneurysms, affecting 2%-5% of the population, pose a significant challenge to neurosurgeons due to their potential to cause subarachnoid haemorrhage and high mortality rates. Intraoperative angiography is necessary for effective surgical planning and indocyanine green video angiography (ICG-VA) has emerged as a useful tool for real-time visualization of aneurysmal blood flow, aiding in better planning for potential blood flow and detection of aneurysm remnants. This mini narrative review explores the application of ICG-VA in intracranial aneurysm surgery. Compared with conventional dye-based angiography, ICG-VA is safer, more effective and more cost-effective. It can assess haemodynamic parameters, cerebral flow during temporary artery occlusion, completeness of clipping and patency of branch vessels. However, implementing ICG-VA in low- and middle-income countries presents challenges such as financial constraints, limited access to training and expertise, patient selection and consent issues. Addressing these obstacles requires capacity-building, training programmes for neurosurgeons and multidisciplinary teams, technology transfer, equipment donations, public-private partnerships, continued research and development, reducing conventional dye usage, reducing ICG wastage, exploring mechanisms to reuse ICG dyes and advocating for increased government funding and healthcare budgets.

Endoscope-assisted microneurosurgery for intracranial aneurysms: A systematic review and meta-analysis

BACKGROUND

In the surgical approach to treat deep-seated intracranial lesions, endoscopes can be used to assist microsurgical operations and improve outcomes. This technique is often called endoscope-assisted microneurosurgery (EAM). This systematic review and meta-analysis aimed to evaluate the feasibility, safety, and effectiveness of EAM.

METHODS

We performed a meta-analysis of relevant articles identified using PubMed, Embase, and the Cochrane Central Register to assess the efficacy of EAM according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Primary outcomes were repositioning of the definitive clip, better surgical field, the overall and endoscope-related complication rates, mortality, and the rate of follow up.

RESULTS

A total of 10 studies of 1,432 patients with 1,717 aneurysms treated with EAM were included. EAM led to repositioning of the definitive clip in 13% (95% CI, 9%-17%; I₂ = 72.61%; p < 0.001); 77% of aneurysms treated with endoscopically assisted vision and information had a better outcome than that with standard surgery (95% CI, 52%-95%; I₂ = 97.63%; p < 0.001). There was an overall complication rate of 6% (95% CI, 1%-13%; I₂ = 91.39%; p < 0.001). The incidence of endoscope-related complications was 0% (95% CI, 0%-1%; I₂ = 64%; p < 0.001). The mortality was 0% (95% CI, 0-1%; I₂ = 0.0%); and 94% of patients had an excellent to good recovery and good outcome (95% CI, 88%-98%; I₂ = 88.42%; p < 0.001).

CONCLUSIONS

Our comprehensive study showed that EAM for intracranial aneurysms is feasible, the safety of the surgery is good, and the patients have a good prognosis, Therefore, we think EAM can be more widely adopted in the future.