Microsurgery for intracranial aneurysms: A qualitative survey on technical challenges and technological solutions

Abstract

IntroductionMicrosurgery for the clipping of intracranial aneurysms remains a technically challenging and high-risk area of neurosurgery. We aimed to describe the technical challenges of aneurysm surgery, and the scope for technological innovations to overcome these barriers from the perspective of practising neurovascular surgeons.Materials and MethodsConsultant neurovascular surgeons and members of the British Neurovascular Group (BNVG) were electronically invited to participate in an online survey regarding surgery for both ruptured and unruptured aneurysms. The free text survey asked three questions: what do they consider to be the principal technical barriers to aneurysm clipping? What technological advances have previously contributed to improving the safety and efficacy of aneurysm clipping? What technological advances do they anticipate improving the safety and efficacy of aneurysm clipping in the future? A qualitative synthesis of responses was performed using multi-rater emergent thematic analysis.ResultsThe most significant reported historical advances in aneurysm surgery fell into five themes: (1) optimising clip placement, (2) minimising brain retraction, (3) tissue handling, (4) visualisation and orientation, and (5) management of intraoperative rupture. The most frequently reported innovation by far was indocyanine green angiography (84% of respondents). The three most commonly cited future advances were hybrid surgical and endovascular techniques, advances in intraoperative imaging, and patient-specific simulation and planning.ConclusionsWhile some surgeons perceive that the rate of innovation in aneurysm clipping has been dwarfed in recent years by endovascular techniques, surgeons surveyed highlighted a broad range of future technologies that have the potential to continue to improve the safety of aneurysm surgery in the future.

Emerging anesthesia techniques for managing intraoperative rupture of cerebral aneurysms

“…Coupled with the sudden and unexpected nature of the event, an IAR can create great stress for the surgeon and the anesthesiologist. In a survey of neurovascular surgeons, IAR was identified as one of the major technical challenges to aneurysm clipping 1 …”

“…In a survey of neurovascular surgeons, IAR was identified as one of the major technical challenges to aneurysm clipping. 1 Despite the advancement of endovascular techniques, microsurgical clipping performed via a craniotomy remains indicated for a variety of reasons, such as for patients with subarachnoid hemorrhage (SAH) with mass effect, cranial nerve palsies due to compression by the aneurysm, wide-necked bifurcation or irregularly-shaped aneurysms, and ones that have failed endovascular treatment. 2 As microsurgical clipping becomes reserved for more complex indications, the risk of IAR is likely to remain significant.…”