Is the surgical repair of unruptured atherosclerotic aneurysms at a higher risk of intraoperative ischemia?

Szelényi, Andrea; Beck, Jürgen; Strametz, Reinhard; Blasel, Stella; Oszvald, Ági; Raabe, Andreas; Seifert, Volker

doi:10.1016/j.clineuro.2010.10.012

Cited by 26 publications

(34 citation statements)

References 28 publications

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“…Previous studies have reported that overall morbidity rates of surgery for UIAs range between 2.2% and 13.7%, 1,3,18,36,47,67 with ischemic complications being a major cause of morbidity. 5,9,36,41,54,59 Thus, preventing ischemic complications during UIA surgery should reduce the morbidity rate.Currently, various methods are used for preventing is-ABBREVIATIONS AChA = anterior choroidal artery; DSA = digital subtraction angiography; EP = evoked potential; GOS = Glasgow Outcome Scale; ICG = indocyanine green; ICH = intracerebral hemorrhage; MEP = motor evoked potential; mRS = modified Rankin Scale; MVD = microvascular Doppler; NMB = neuromuscular blockade; NPV = negative predictive value; PPV = positive predictive value; SAH = subarachnoid hemorrhage; SDH = subdural hemorrhage; SEP = somatosensory evoked potential; UIA = unruptured intracranial aneurysm.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 falsenegative results from intraoperative evoked potential (EP) monitoring, but the incidence and possible causes for these results are not well established.…”

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

Chung¹,

Park²,

Hong³

et al. 2019

Journal of Neurosurgery

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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.

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

Chung¹,

Park²,

Hong³

et al. 2019

Journal of Neurosurgery

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“…22,23 It is possible that the fragile plaque migrates distally during the clipping procedure. We had a few patients who had silent ischemic lesions on diffusion-weighted imaging, as retrospectively proved by operative video.…”

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confidence: 99%

Vascular Wall Imaging of Unruptured Cerebral Aneurysms with a Hybrid of Opposite-Contrast MR Angiography

Matsushige

Akiyama

Okazaki

et al. 2015

AJNR Am J Neuroradiol

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“…All procedures were conducted using intraoperative monitoring (IOM) of somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs). 42 The patients were kept normovolemic with a mean arterial pressure (MAP) of 70-100 mm Hg. Additionally, mild hypothermia (35°C) and burst suppression were induced before aneurysm clipping.…”

Section: Surgical Procedures and Intraoperative Monitoringmentioning

confidence: 99%

Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: results of an interdisciplinary prospective trial

Konczalla¹,

Platz²,

Fichtlscherer

et al. 2018

Journal of Neurosurgery

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OBJECTIVE To date, treatment of complex unruptured intracranial aneurysms (UIAs) remains challenging. Therefore, advanced techniques are required to achieve an optimal result in treating these patients safely. In this study, the safety and efficacy of rapid ventricular pacing (RVP) to facilitate microsurgical clip reconstruction was investigated prospectively in a joined neurosurgery, anesthesiology, and cardiology study. METHODS Patients with complex UIAs were prospectively enrolled. Both the safety and efficacy of RVP were evaluated by recording cardiovascular events and outcomes of patients as well as the amount of aneurysm occlusion after the surgical clip reconstruction procedure. A questionnaire was used to evaluate aneurysm preparation and clip application under RVP. RESULTS Twenty patients (mean age 51.6 years, range 28-66 years) were included in this study. Electrode positioning was easy in 19 (95%) of 20 patients, and removal of electrodes was easily accomplished in all patients (100%). No complications associated with the placement of the pacing electrodes occurred, such as cardiac perforation or cardiac tamponade. RVP was applied in 16 patients. The mean aneurysm size was 11.1 ± 5.5 mm (range 6-30 mm). RVP proved to be a very helpful tool in aneurysm preparation and clip application in 15 (94%) of 16 patients. RVP was used for a mean duration of 60 ± 25 seconds, a mean heart rate of 173 ± 23 bpm (range 150-210 bpm), and a reduction of mean arterial pressure to 35-55 mm Hg. RVP leads to softening of the aneurysm sac facilitating its mobilization, clip application, and closure of the clip blades. In 2 patients, cardiac events were documented that resolved without permanent sequelae in both. In every patient with successful RVP (n = 14) a total or near-total aneurysm occlusion was documented. In the 1 patient in whom the second RVP failed due to pacemaker electrode dislocation, additional temporary clipping was required to secure the aneurysm, but was not as sufficient as RVP. This led to an incomplete clipping of the aneurysm and finally a remnant on postoperative digital subtraction angiography. A pacemaker lead dislocation occurred in 3 (19%) of 16 patients, but intraoperative repositioning requires less than 20 seconds. Outcome was favorable in all patients according to the modified Rankin Scale. CONCLUSIONS To the best of the authors' knowledge this is the first prospective interdisciplinary study of RVP use in patients with UIAs. RVP is an elegant technique that facilitates clip reconstruction in complex UIAs. The safety of the procedure is good. However, because this procedure requires extensive preoperative cardiological workup of the patient and an experienced neurosurgery and neuroanesthesiology team with much cerebrovascular expertise, actually it remains reserved for selected elective cases and highly specialized centers. Clinical trial registration no.: NCT02766972 (clinicaltrials.gov).

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Is the surgical repair of unruptured atherosclerotic aneurysms at a higher risk of intraoperative ischemia?

Cited by 26 publications

References 28 publications

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

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

Vascular Wall Imaging of Unruptured Cerebral Aneurysms with a Hybrid of Opposite-Contrast MR Angiography

Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: results of an interdisciplinary prospective trial

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