Intraoperative aneurysm rupture — the main complication in microsurgery of cerebral aneurysms

Abstract

Objective: To analyze the impact of the intraoperative risk factors of intraoperative aneurysm rupture (IAR) and IRA in clipping a brain aneurysm on the results of surgical treatment.Materials and methods. A retrospective analysis of surgical treatment of 138 (11.4 %) patients, with IAR during clipping of a brain aneurysm in the period from 2011 to 2017, was performed. The total number of operations for clipping cerebral aneurysms in our observations is 1,208 (100 %). Preoperative examination of patients included clinical and neurological examination, brain CT, cerebral angiography (CAG), duplex scan of the main vessels of the head and neck. The radicality of clipping was controlled by puncture of the aneurysmal dome, using intraoperative Doppler and postoperative CAG.Results. IAR occurred at all stages of surgery preceding the exclusion of an aneurysm from the bloodstream, but prevailed in its isolation and clipping. Non-contact arterial aneurysm (AA) rupture was observed in 6 (4.35 %) patients. Ischemic lesions according to postoperative MSCT of the brain were observed in 2 (1.45 %) patients with noncontact intraoperative ruptures of AA MCA on the right. The contact intraoperative rupture of AA was observed in 132 (95.65 %) cases. The results of treatment were evaluated at hospital discharge on the Glasgow scale results, according to which we received the following data: 5 points — 67 patients (48.55 %); 4 points — 17 (12.32 %); 3 points — 37 (26.81 %); 2 points — 0; 1 point — 17 (12.32 %) cases.Conclusions:1. Intraoperative rupture brain aneurysm is the most common intraoperative complication, which threatens massive blood loss during surgery, forces the surgeon to change surgical tactics and often perform aggressive manipulations, such as forced temporal clipping.2. Analyzing the surgical interventions of clipping of cerebral AA in which IAR took place, the most common risk factors for IAR were found to be brain swelling, large AA, atherosclerotic changes of cerebral vessels, high blood pressure during surgery, pronounced arachnoid changes.3. According to our observations data, most of the IARs occurred with AA of the ACA-ACoA complex (84 cases — 60.87 %), which is related to hemodynamic features, anatomic variability of the ACA-ACoA complex and frequent localization of AA in this area.4. In our study, IAR occurs more frequently at the stage of AA excretion (116 cases — 84.06 %) and directly during AA clipping (7 cases — 5.07 %); less frequently — at the stage of AA artery extraction (6 — 4.35 %), at the stage of early arachnoid dissection (3 — 2.17 %) and at the craniotomy stage — non-contact IAR (6 — 4.35 %).