Limitation of temporary vascular occlusion during aneurysm surgery

Ogawa, Akira; Sato, Hiroo; Sakurai, Yasuhisa; Yoshimoto, Takashi

doi:10.1016/0090-3019(91)90159-7

Cited by 46 publications

(12 citation statements)

References 13 publications

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“…Previous clinical studies have reviewed various anesthetic and surgical protocols instituted during temporary focal ischemia and have measured outcome based on postoperative neurological condition and radiographic findings. [2,3,10,11,13,[18][19][20]23,24,[28][29][30][31][32]34,36,40,42,44,50,51] These investigators have proclaimed the value of intravenous brain-protection (IVBP) anesthesia and intraoperative electrophysiological monitoring techniques, stressed the importance of decreased tolerance to ischemia in elderly patients and those with poor Hunt and Hess grades, and reported infarction rates related to the nature and duration of arterial occlusion.…”

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confidence: 99%

Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection

Lavine¹,

Masri²,

Levy³

et al. 1997

FOC

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The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of brain-protection anesthetics, a group of patients treated with the intravenous agents, propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane. Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous brain-protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the isoflurane (ISO) group. In the ISO group, the mean duration of temporary occlusion was 3.9 ± 2.2 minutes for patients without infarction versus 12.2 ± 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 ± 10.6 minutes for patients without infarction and 18.5 ± 9.9 minutes for patients with infarction in the IVBP group. All patients in the ISO group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group. Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at a decreased risk. It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving ISO when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and patients with multiple aneurysms need further evaluation before specific recommendations can be made.

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confidence: 99%

Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection

Lavine¹,

Masri²,

Levy³

et al. 1997

FOC

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“…The main prognostic factor in determining ischemic damage is confirmed to be the occlusion time of the local arterial circulation as reported in the literature 1,11,12,13,18,19 . The temporary clipping of the afferent artery to the sac provides local hypotension, reduces the risk of intra-operative rupture and allows an adequate dissection of the neck with correct positioning of the definitive clip 7,8 .…”

Section: Discussionmentioning

confidence: 65%

Temporary Clipping in Intracranial Aneurysm Surgery

Bellotti

Panzarasa

Arrigoni

et al. 2002

Rivista di Neuroradiologia

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The intra-operative rupture of intracranial aneurysms (IA) occurs in 5-30% of cases as reported in the literature. This event is frequently associated with an increase in mortality and morbidity. The aim of this study was to evaluate the prognostic importance of temporary clipping in intracranial aneurysm surgery. A series of 304 cases of IA treated surgically were selected by excluding giant or HuntHess grade >3 aneurysms. Two groups of patients were compared: one of 157 cases that had temporary clipping (TC) during surgery and the other of 147 patients who did not have TC.The neuroprotective measures used were the infusion of Thiopental and maintenance of adequate blood pressure by use of Bitartrate Metaraminol and Ephedrine. The surgical complications, chiefly intraoperative rupture of the sac and consequences of malpositioning the clip with associated clinical complications, were considered. The two groups were compared using χ 2 that showed a statistically significant reduction of the surgical complications in those patients who had TC. The associated poor clinical outcome was reduced from 7.5% to 2.5%. The main prognostic factor in determining the ischemic damage was the occlusion time of the local arterial circulation. The mean occlusion time in these patients was limited to four minutes and in only 12 cases reached 15-16 minutes without ischemic complications. Temporary clipping reduces the risk of intra-operative rupture of aneurysm and permits a better dissection of the sac with an adequate positioning of the definitive clip. In cases of small aneurysm with an easily accessible neck (that predict a temporary occlusion of the local arterial circulation) we consider the maintenance of optimal blood pressure very important. However we do not consider it essential to use electrophysiologic monitoring or other particular techniques of neuroprotection (which are vital in the surgery of giant or complex aneurysms).Il "clippaggio" temporaneo nella chirurgia degli aneurismi intracranici RIASSUNTO -La rottura intraoperatoria degli aneurismi intracranici viene segnalata in letteratura con percentuali variabili dal 5 al 30% dei casi. Questo evento è frequentemente associato ad un aumento della mortalità e morbilità. Lo scopo di questo nostro lavoro è quello di analizzare il valore prognostico del clippaggio temporaneo nella chirurgia degli aneurismi intracranici. Una serie di 304 aneurismi intracranici operati è stata raccolta escludendo gli aneurismi giganti o i gradi Hunt-Hess superiori al III. Sono stati confrontati due gruppi di pazienti: nel primo, di 157 casi, è stato impiegato il clippaggio temporaneo durante l'intervento, mentre nel secondo, 147 pazienti, ciò non è stato utilizzato.Le misure di neuroprotezione adottate sono state l'infusione di tiopental ed il mantenimento di una pressione arteriosa adeguata con l'impiego del bitartrato di metaraminolo ed efedrina.

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“…A clipagem temporária de artérias aferentes e eferentes ao aneurisma foi pioneiramente descrita por Susuki 13 com duração inferior a 40 minutos, quando associado ao coquetel de Sendai. Hoje, alguns autores 14,15 demonstram que rotineiramente os pacientes toleram em torno de 14 minutos de clipagem temporária durante a dissecção e clipagem definitiva do aneurisma. A maioria deles refere eventos isquêmicos com clipagem temporária acima de 10 minutos 14,15 .…”

Section: Discussionunclassified

Ruptura aneurismática intraoperatória junto ao colo: sugestão de manuseio cirúrgico

Andrade

Braga

2002

Arq. Neuro-Psiquiatr.

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RESUMO -A ruptura aneurismática intraoperatória de um aneurisma intracraniano pode comprometer dramaticamente um procedimento neurocirúrgico delicado, diminuindo as chances de uma evolução favorável do paciente. A ruptura ordinariamente se dá junto ao domus do aneurisma, causando icto.Com menor frequência, a ruptura pode se processar junto ao colo, em um ponto entre o vaso principal e o saco aneurismático. Isso causa um grande problema ao neurocirurgião; a colocação de um clipe de aneurisma neste local só irá aumentar a hemorragia. Nossa sugestão técnica resume-se à clipagem do aneurisma sobre um pequeno fragmento de músculo temporal colocado no local da ruptura. É bastante simples mas bastante útil, devendo ser lembrada no momento da ruptura. Não encontramos descrição semelhante nos principais livros e artigos que se referem à ruptura aneurismática durante a cirurgia.PALAVRAS-CHAVE: aneurisma intracraniano, ruptura intraoperatória.Intraoperative rupture in the aneurysmal neck: suggestion for surgical management Intraoperative rupture in the aneurysmal neck: suggestion for surgical management Intraoperative rupture in the aneurysmal neck: suggestion for surgical management Intraoperative rupture in the aneurysmal neck: suggestion for surgical management Intraoperative rupture in the aneurysmal neck: suggestion for surgical management ABSTRACT -The per operative rupture of the aneurysm during dissection impairs the delicate microsurgical procedure and increases the risk of a bad evolution for the patient. During operation the aneurysm generally ruptures in its belly but it could happen just in its colon, between the main vessel and the sac. This brings a serious problem to the neurosurgeon once the placement of a clip at this place will increase the bleeding. Our technical suggestion is to perform the clipage over a small piece of temporal muscle gently placed over the hole of bleeding after temporary clipage. This is a very simple procedure but very useful that must be reminded in such cases. We did not found a similar description in the main books and articles related with intraoperative aneurysm rupture.KEY WORDS: intracranial aneurysm, intraoperative rupture.Com todos os avanços tecnológicos existentes, como a utilização do microscópio, do material cirúr-gico e de várias técnicas cirúrgicas, a ruptura aneurismática intraoperatória é uma complicação importante no que diz respeito à morbimortalidade. Esta complicação ocorre em cerca de 19% dos casos operados, com um índice de morbimortalidade elevado, variando entre 15% 1 e 38% 2 . A ruptura ocorre em três períodos específicos: 1. pré-dissecção (antes da craniotomia, durante a craniotomia, durante a abertura dural e durante a retração cerebral inicial) em 7% ; 2. dissecção do aneurisma, em 48%; e 3. aplicação do clipe, em 45% 2,3 . O maior percentual de ruptura intraoperatória ocorre durante os perío-dos de dissecção do aneurisma e colocação do clipe; quase sempre reflete um erro de técnica com a dissecção inadequada das estruturas anatômicas. Para o controle d...

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Limitation of temporary vascular occlusion during aneurysm surgery

Cited by 46 publications

References 13 publications

Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection

Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection

Temporary Clipping in Intracranial Aneurysm Surgery

Ruptura aneurismática intraoperatória junto ao colo: sugestão de manuseio cirúrgico

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