The Impact of Temporary Artery Occlusion During Intracranial Aneurysm Surgery on Long-Term Clinical Outcome: Part II. The Patient Who Undergoes Elective Clipping

Griessenauer, Christoph J.; Poston, Tyler; Shoja, Mohammadali Mohajel; Mortazavi, Martin M.; Falola, Michael; Tubbs, R. Shane; Fisher, Winfield S.

doi:10.1016/j.wneu.2013.02.067

Cited by 26 publications

(36 citation statements)

References 18 publications

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“…[7] Griessenauer, in two follow-up studies of patients who underwent temporary clipping during treatment of cerebral aneurysms, also found no association between duration of clipping and outcome, even with an average time as high as 19 min. [11,12]…”

Section: Discussionmentioning

confidence: 99%

Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil

Soares

Velho

Antunes

2019

Surgical Neurology International

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Background: The aim of the study was to characterize the clinical profile of patients with anterior communicating artery (ACoA) aneurysms and examine potential correlations between clinical findings, aneurysm morphology, and outcome. Methods: A review of medical records and diagnostic neuroimaging reports of patients treated at a neurosurgical service in Porto Alegre, Brazil, between August 2008 and January 2015 was performed. Results: During the period, 100 patients underwent surgery for ACoA aneurysms. Fifteen had unruptured aneurysms and 85 had ruptured aneurysms. Ruptured aneurysms had a higher aspect ratio than unruptured ones (2.37 ± 0.71 vs. 1.93 ± 0.51, P = 0.02). Intraoperative rupture occurred in 3%, and temporary clipping was performed in 15%. Clinical vasospasm occurred in 43 patients with ruptured aneurysms (50.6%). Overall, mortality was 26%; 25 patients in the ruptured group (29.4%) and one in the unruptured group (6%). The Glasgow Outcome Scale (GOS) was favorable (GOS 4 or 5) in 54% of patients, significantly more so in those with unruptured aneurysms (P = 0.01). In patients with ruptured aneurysms, mortality was associated with preoperative Hunt and Hess (HH) score (P < 0.001), hydrocephalus (P < 0.001), and clinical complications (P < 0.001). Unfavorable outcomes were associated with HH score (P < 0.001), Fisher grade (P = 0.015), clinical vasospasm (P = 0.012), external ventricular drain (P = 0.015), hydrocephalus (P < 0.001), and presence of clinical complications (P = 0.001). In patients with unruptured aneurysms, presence of clinical complications was the only factor associated with mortality (P < 0.001). Conclusion: Despite advances in the management of subarachnoid hemorrhage and surgical treatment of aneurysms, mortality is still high, especially due to clinical complications.

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Section: Discussionmentioning

confidence: 99%

Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil

Soares

Velho

Antunes

2019

Surgical Neurology International

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“…Temporary clipping with a mean duration of 19 minutes had no negative influence on clinical outcome. 11,12 It is well known that vasospasm and DCI are the main contributors to poor outcome in aSAH patients. Despite not being investigated in these 2 studies, the lack of effect of temporary clipping on outcome can be seen as a surrogate parameter for a lack of effect of temporary clipping on the incidence of vasospasm and DCI.…”

Section: Does Microsurgery Contribute To Vasospasm?mentioning

confidence: 99%

The impact of temporary clipping during aneurysm surgery on the incidence of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Malinova

Schatlo

Voit

et al. 2018

Journal of Neurosurgery

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OBJECTIVE Clipping of a ruptured intracranial aneurysm requires some degree of vessel manipulation, which in turn is believed to contribute to vasoconstriction. One of the techniques used during surgery is temporary clipping of the parent vessel. Temporary clipping may either be mandatory in cases of premature rupture (rescue) or represent a precautionary or facilitating surgical step (elective). The aim of this study was to study the association between temporary clipping during aneurysm surgery and the incidence of vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) in a large clinical series. METHODS Seven hundred seventy-eight patients who underwent surgical aneurysm treatment after aSAH were retrospectively included in the study. In addition to surgical parameters, the authors recorded transcranial Doppler (TCD) sonography-documented vasospasm (TCD-vasospasm, blood flow acceleration > 120 cm/sec), delayed ischemic neurological deficits (DINDs), and delayed cerebral infarction (DCI). Multivariate binary logistic regression analysis was applied to assess the association between temporary clipping, vasospasm, DIND, and DCI. RESULTS Temporary clipping was performed in 338 (43.4%) of 778 patients during aneurysm surgery. TCD sonographic flow acceleration developed in 370 (47.6%), DINDs in 123 (15.8%), and DCI in 97 (12.5%). Patients with temporary clipping showed no significant increase in the incidence of TCD-vasospasm compared with patients without temporary clipping (49% vs 48%, respectively; p = 0.60). DINDs developed in 12% of patients with temporary clipping and 18% of those without temporary clipping (p = 0.01). DCI occurred in 9% of patients with temporary clipping and 15% of those without temporary clipping (p = 0.02). The need for rescue temporary clipping was a predictor for DCI; 19.5% of patients in the rescue temporary clipping group but only 11.3% in the elective temporary clipping group had infarcts (p = 0.02). Elective temporary clipping was not associated with TCD-vasospasm (p = 0.31), DIND (p = 0.18), or DCI (p = 0.06). CONCLUSIONS Temporary clipping did not contribute to a higher rate of TCD-vasospasm, DIND, or DCI in comparison with rates in patients without temporary clipping. In contrast, there was an association between temporary clipping and a lower incidence of DINDs and DCI. There is no reason to be hesitant in using elective temporary clipping if deemed appropriate.

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“…In contrast to temporary clipping, where several minutes of flow arrest are usually achieved, the duration achieved by RVP is shorter. 17 Also in contrast to temporary clipping, the IOM identified no alterations of EEGs, SSEPs, and MEPs, and cerebral oxygenation was also not affected. 2 Additionally, temporary clipping is associated with the risk of vessel wall injury or thromboembolic complications.…”

Section: Why Rvp and Not Temporary Clip Placement Or Revascularization?mentioning

confidence: 86%

“…5,13 Especially in the presence of vessel-wall sclerosis or a prolonged temporary clipping interval, postoperative ischemic deficits may occur. 17 Sometimes the temporary clip itself might limit the application of the permanent clip, especially in narrow surgical corridors. 29 For paraclinoid aneurysms (Fig.…”

Section: Why Rvp and Not Temporary Clip Placement Or Revascularization?mentioning

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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The Impact of Temporary Artery Occlusion During Intracranial Aneurysm Surgery on Long-Term Clinical Outcome: Part II. The Patient Who Undergoes Elective Clipping

Cited by 26 publications

References 18 publications

Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil

Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil

The impact of temporary clipping during aneurysm surgery on the incidence of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

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

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