“Awake” clipping of cerebral aneurysms: report of initial series

Abstract

ABBREVIATIONS ACoA = anterior communicating artery; CVA = cerebrovascular accident; EEG = electroencephalography; ICA = internal carotid artery; LOS = length of stay; MCA = middle cerebral artery; MEP = motor evoked potential; mRS = modified Rankin Scale; NIS = National Inpatient Sample; SSEP = somatosensory evoked potential; UIA = unruptured intracranial aneurysm; VA = vertebral artery. OBJECTIVE Risk of ischemia during aneurysm surgery is significantly related to temporary clipping time and final clipping that might incorporate a perforator. In this study, the authors attempted to assess the potential added benefit to patient outcomes of "awake" neurological testing when compared with standard neurophysiological testing performed under general anesthesia. The procedure is performed after the induction of conscious sedation, and for the neurological testing, the patient is fully awake. METHODS The authors conducted an institutional review board-approved prospective study of clipping unruptured intracranial aneurysms (UIAs) in 30 consecutive adult patients who underwent awake clipping. The end points were the incidence of stroke/cerebrovascular accident (CVA), death, discharge to a long-term facility, length of stay, and 30-day modified Rankin Scale score. All clinical and neurophysiological intraoperative monitoring data were recorded. RESULTS The median patient age was 52 years (range 27-63 years); 19 (63%) female and 11 (37%) male patients were included. Twenty-seven (90%) aneurysms were anterior, and 3 (10%) were posterior circulation aneurysms. Five (17%) had been coiled previously, 3 (10%) had been clipped previously, 2 (7%) were partially calcified, and 2 (7%) were fusiform aneurysms. Three patients developed synchronous clinical neurological and neurophysiological changes during temporary clipping with consequent removal of the temporary clip and reversal of those clinical and neurophysiological changes. Three patients developed asynchronous clinical neurological and neurophysiological changes. These 3 patients developed hemiparesis without changes in neurophysiological monitoring results. One patient developed linked clinical neurological and neurophysiological changes during final clipping that were not reversed by reapplication of the clip, and the patient had a CVA. Four patients with internal carotid artery ophthalmic segment aneurysms underwent visual testing with final clipping, and 1 of these patients required repositioning of the clip. Three patients who required permanent occlusion of a vessel as part of their aneurysm treatment underwent a 10-minute intraoperative clinical respective-vessel test occlusion. The median length of stay was 3 days (range 1-5 days). The median modified Rankin Scale score was 1 (range 0-3). All of the patients were discharged to home from the hospital except for 1 who developed a CVA and was discharged to a rehabilitation facility. There were no deaths in this series. CONCLUSIONS The 3 patients who developed neurological deterioration without a concomitant neurophysi...

Rehabilitation after Clipping of Cerebral Aneurysms without Acute Subarachnoid Hemorrhage: Outcome Analysis of 100 Consecutive Cases

“…Both retrospective control and prospective awake cohorts fared better than NIS data. With outcome data and a clip occlusion rate well within the range of the actual literature, [7][8][9][10][11][12][13] posterior location of the aneurysm and the deviation of the clinical result from an optimal path marked as complication, govern the risk of rehabilitation in our patient cohort. However, rehabilitation, especially long-term care, should not be stated without a detailed description of relation to outcome.…”

Innovations in the Surgery of Cerebral Aneurysms: Enhanced Visualization, Perfusion, and Function Monitoring

“…However, in selected case of clipping of the aneurysms of the dominant hemisphere, the monitoring of the language function and thus awake surgery would be useful. Abdulrauf et al reported awake surgery in 30 unruptured cerebral aneurysms [47]. In three patients the strategy affected the outcome, since the removal of the temporary clipping determined the reversal of the clinical neurological and neurophysiological changes.…”

Neurosurgery in conscious patients: forward to the past

“…И вот одна из последних публикаций на эту тему, но это уже анализ серии из 30 клинических наблюдений. Работа была опубликована в конце 2016 г. в уважаемом издании -Journal of Neurosurgery и по своему содержанию бесспорно достойна обсуждения [79]. Авторы в серии из 30 пациентов с неразорвавшимися аневризмами (!)…”