Intraoperative Aneurysm Rupture Research Articles

Microsurgical treatment of ophthalmic artery aneurysm, a case series of 55 patients with long-term follow-up

BackgroundOphthalmic artery aneurysm (OAA) can be secured in endovascular or microsurgical approaches. Still there are controversies in technique selection and their long term outcomes.MethodsAll the patients with OAA were treated microsurgically and followed. Demographic data, neurological status, physical examination findings, angiographic data, operation details, and intraoperative and postoperative events were recorded and analyzed. P < 0.05 was considered significant.ResultsAmong 55 patients, 38 were females (69.1%). Median preoperative glasgow coma scale (GCS), Fisher Grade, and Hunt and Hess(HH) scores were 15, 1 and 1, respectively. The most common neurologic manifestation was visual problems (n = 15). The most common anatomical projection was medial (43.6%) oriented lesions. 85.5% of them only had 1 ophthalmic aneurysm while multiple aneurysms were reported in 14.6%. In 52 patients temporary clip was used. in 21 patients (38.2%) intraoperative aneurysm rupture occurred. Larger aneurysm size and preoperative hydrocephalus were associated with higher rates of aneurysm rupture (P = 0.003 and 0.031). 28.5% of the patients with visual problems had clinical improvement in the postoperative period. The mean follow-up period was 5 years. Follow-up angiography showed a 100% obliteration rate with a 0.0% recurrence rate. Median values for follow-up glasgow outcome scale and modified Rankin scale were 5 and 0, respectively. favorable neurological outcomes were associated with better primary GCS and HH scores.ConclusionOAA microsurgery is an effective and safe procedure with significant improvement in both visual and neurological status. Low recurrence rate and excellent clinical recovery are the most important advantages of microsurgery in OAA treatment.

The Art of Cerebral Revascularization: An Illustrative Case Series of Bypass Techniques for Complex Intracranial Aneurysms

Complex intracranial aneurysms (CIAs) comprise a subset of lesions with defiant vascular architecture, difficult access, and prior treatment. Surgical management of CIAs is often challenging and demands an assessment on a case-by-case basis. The generational evolution of bypass surgery has offered a long-standing potential for effective cerebral revascularization. Herein, we aim to illustrate a single-center experience treating CIAs. The authors conducted a retrospective analysis of clinical records of patients treated with cerebral revascularization techniques at Hospital Nacional Dos de Mayo, Lima, Peru during 2018-2022. Relevant data were collected, including patient history, aneurysm features on imaging, preoperative complications, the intraoperative course, aneurysm occlusion rates, bypass patency, neurological function, and postoperative complications. Seventeen patients (70.59% female; median age: 53 years) with 17 CIAs (64.7% saccular; 76.5% ruptured) were included. The most common clinical presentation included loss of consciousness (70.6%) and headaches (58.8%). Microsurgical treatment included first, second, and third-generation bypass. In 47.1% of cases, an anastomosis between the superior temporal artery (STA) and the M3 segment was predominantly used, followed by an A3-A3 bypass (29.4%), STA-M2 bypass (17.6%), and an external carotid artery to M2 bypass (5.9%). The intraoperative aneurysm rupture rate was 11.8%. Postoperative complications included ischemia (40%), cerebrospinal fluid fistulas (26.7%), and pneumonia (20%). At hospital discharge, the median Glasgow Coma Scale score was 14 (range: 10-15). At the six-month follow-up, 82.4% of patients had a modified ranking scale (mRS) score ≤2, bypass patency was present in all cases, and the morbidity rate was 17.6%. CIAs represent a spectrum of defiant vascular lesions with a poor natural history. Bypass surgery offers the potential for definitive treatment. Our case series illustrated the predominant role of cerebral revascularization of CIAs with a critical case-by-case approach to provide optimal outcomes in a limited-resource setting.

A Comparison of Perioperative Complications and Outcomes in Patients Undergoing Cerebral Aneurysm Clipping Performed Ultra-Early (≤ 24 hours) versus Late (&gt; 24 hours): A 7-Year Retrospective Study of 302 Patients

Abstract Objectives The intracerebral aneurysm with subarachnoid hemorrhage (SAH) has a high morbidity and mortality rate. This study aimed to compare the incidences of perioperative complications in ultra-early surgery (within 24 hours) with those in late surgery (&gt; 24 hours). Methods Retrospective data were reviewed for 302 patients who underwent craniotomies with aneurysm clipping between January 2014 and December 2020. Perioperative data were obtained from the medical records and reviewed by the investigators. The complications were compared between ultra-early and late operations. We were interested in major complications such as delayed ischemic neurologic deficit (DIND), intraoperative aneurysm rupture (IAR), and anesthesia-related complications. The short-term (in hospital) and long-term (1 year) outcomes in patients with or without DIND and IAR were compared. The collected data was statistically analyzed. Results Three hundred and two patients were analyzed, and 264 patients had completed follow-up. The ultra-early cases (150 patients) had a higher American Society of Anesthesiologists physical status, a lower Glasgow Coma Scale, and higher Hunt and Hess scales. The surgeons operated on more cases of the anterior cerebral artery as ultra-early operations. The incidence rates of DIND, IAR, severe hemodynamic instability, and cardiac arrest were 5.6, 8.3, 6.3, and 0.3%, respectively, which were not different between groups. However, the reintubation rate was higher in the ultra-early surgery cases (0 vs. 3.3%, p = 0.023). The DIND and IAR patients had poorer short-term (in hospital) outcomes. Conclusions There were no differences in major complications between ultra-early and late craniotomy with aneurysm clipping. However, the reintubation rate was strikingly higher in the ultra-early group. Patients with major complications had early, unfavorable outcomes.

Comparative analysis of supra-orbital keyhole approach and pterional approach for surgical clipping of intracranial anterior circulation aneurysms in patients with favorable Hunt and Hess grades

IntroductionTraditional large craniotomies have been the standard for aneurysm surgery. However, minimally invasive “keyhole” approaches have gained popularity for aneurysm clipping in recent years. This study focuses on Supra-Orbital Keyhole Approach (SOKHA),its use in clipping of aneurysms of the anterior Circle of Willis. Here we share the experiences of a tertiary care center regarding aneurysm clipping using SOKHA. Materials and methodsWe retrospectively reviewed 166 cases involving aneurysm clipping, with 62 patients undergoing SOKHA and 104 patients undergoing the pterional approach. Factors evaluated included patient demographics, aneurysm characteristics, incidence of intraoperative complications, temporary-clipping usage, and postoperative clinical outcomes. Glasgow Outcome Scale scores were utilized to assess clinical outcomes. ResultsThe study found that both the SOKHA and pterional approaches were similar in terms of age distribution, Hunt and Hess grades, and the incidence of hydrocephalus. The majority of aneurysms in both groups were anterior communicating artery aneurysms.Hydrocephalus was observed in 14.5 % of SOKHA cases and 13.5 % of pterional cases. Intraoperative aneurysm rupture occurred in 8.1 % of SOKHA cases and 7.7 % of pterional cases. There were no mortalities in the SOKHA group, while the pterional group had 1.92 % mortality rate. At the last follow-up, 77.4 % of SOKHA cases and 75.9 % of pterional cases had a favorable outcome (Glasgow Outcome Scale IV and V), with no significant difference. ConclusionSOKHA offers the advantage of potential cosmetic benefit with neurological outcomes comparable to those of the traditional pterional approach, in properly selected patients.

Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes.

Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms. Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics. Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers. Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

Intraoperative Rupture of Aneurysms: Better Avoid than Mitigate.

Intraoperative Rupture of Aneurysms: Better Avoid than Mitigate.

Aneurysm Wrapping as an Adjunct of Clipping of a Premature Rupture of the Middle Cerebral Artery Aneurysm

Aneurysms, abnormal dilatations on cerebral arterial walls, pose a significant health concern due to the morbidity and mortality associated with ruptures causing subarachnoid hemorrhage. The risk of rupture is influenced by aneurysm size and location. Surgical clipping is the preferred treatment, especially for middle cerebral artery (MCA) aneurysms, despite recent endovascular advancements. Intraoperative premature rupture poses a critical challenge, requiring swift decision-making and efficient management techniques. We describe a case of an intraoperative premature aneurysm rupture managed with muscular wrapping as an adjunct to microsurgical clipping. The patient, with a history of spontaneous intracerebral hematoma, underwent urgent microsurgical clipping for a left MCA aneurysm. Premature rupture occurred during clipping, necessitating the use of a muscle patch and fibrin glue for wrapping. The wrapping technique, originally developed for unruptured aneurysms, induces fibrotic scar formation, enhancing vascular stability. Cotton, a common wrapping material, elicits chronic inflammation. Autologous tissues and synthetic materials, like muscle, offer alternatives with potential benefits. Factors associated with increased rupture risk include aneurysm location, irregular shape, and prior rupture. Vigilance and preparedness are crucial, especially for high-risk cases. As the availability of computed tomography scans increases, more aneurysm cases are diagnosed, requiring comprehensive patient assessments before interventions. The presented case demonstrates the effectiveness of on-site wrapping in controlling premature rupture. The combined use of muscle patch and fibrin glue postaneurysmal clipping may assist in preventing rebleeding events. Intraoperative ruptures demand careful consideration, and the described wrapping technique provides a valuable option for managing such complications.

Abstract 180: A Prospective, Single‐Center Study Appraising Aneurysm Embolization using the Balt Optima™ Coil System (APPLY Study)

Introduction Intracranial aneurysms, both ruptured and unruptured, pose a significant risk to the general population. Cases of unruptured intracranial aneurysms (UIA) are estimated to affect roughly 3% of the general population and aneurysmal subarachnoid hemorrhage (aSAH) have an incidence of 8 to 9 people per 100,000. With the advancement of endovascular coil devices, aneurysm embolization with coiling is becoming the more preferred treatment approach compared to craniotomy with microsurgical clipping. The purpose of this study was to assess the safety and efficacy of endovascular coiling using the novel Balt Optima™ Coil System. Methods This study was an investigator‐initiated, prospective, real‐world, single‐center, post‐market study conducted in Thousand Oaks, California. Between 2020 and 2023, thirty cerebral aneurysms were treated with at least 80% utilization of the Balt Optima™ Coil System. The subjects were followed for 6 months (‐4 months/+6 months). Data points were obtained at baseline, procedure, discharge or postoperative day 7, and 6 months follow‐up (‐4 months/+6 months). Primary outcomes were functional status recorded as modified Rankin scores (mRS) and radiographic occlusion rates documented as Raymond‐Roy scores. Serious adverse events including, but not limited to, groin hematoma, periprocedural stroke, intraoperative aneurysm rupture, coil herniation requiring stent placement, and mortality were recorded. Secondary outcomes included coil packing densities, minor complications, procedure duration, disposition after hospitalization, and antithrombotic medication adjustments. Results 30 intracranial aneurysms in 29 individual subjects were included in the study and were treated by a total of 4 neurointerventionalists with at least 80% use of the Balt Optima™ Coil System. One subject had two aneurysms which were treated at two separate occasions, and the subject was consented for both aneurysms to be included in the study. 60% of aneurysms were located along the right anterior circulation and vessels involved mirrored epidemiological data in the literature. 83% of subjects were female, and 50% of aneurysms presented as ruptured. All subjects had a baseline mRS 0‐2. 83% of aneurysms were treated with utilization of an assist device as well. At 6 months follow‐up (‐4 months/+6 months), 80% of subjects had mRS 0‐2. Of the 21 patients with 6 month (‐4 months/+6 months) follow‐up imaging, 15 (71%) had complete aneurysm occlusion (Raymond‐Roy score of 1) and 6 (29%) patients had residual aneurysm neck filling (Raymond‐Roy score of 2). One subject (3%) expired during the hospitalization due to complications unrelated to the aneurysm or coil system, and one subject (3%) was lost to follow‐up. One subject (3%) developed a groin hematoma, one subject (3%) had an intraoperative rupture with no significant clinical consequence, and two subjects (7%) experienced coil herniation requiring stent placement with no clinical sequelae. No subjects (0%) had periprocedural strokes. Conclusion This study demonstrates that the Balt Optima™ Coil System is safe and effective for endovascular treatment of both unruptured and ruptured intracranial aneurysms. Additional data is needed to validate these results and compare to other coil devices on the market.

Anesthetic Management of Intraoperative Aneurysm Rupture: A Narrative Review

Intraoperative aneurysm rupture (IOAR) is a serious and potentially life-threatening complication that can occur during intracranial aneurysm surgery. Understanding the perioperative risk factor contributing to IOAR may help prevention and better handle if it occurs. The anesthesiologist should be familiar with the management of IOAR to facilitate bleeding control and improve perioperative outcome. There is controversy surrounding the management of IOAR. The main goal of management includes promptly securing for control of bleeding as well as maintaining adequate cerebral perfusion and providing neuroprotection. The purpose of the present article was to review the anesthetic management during IOAR. The authors focused on the hemodynamic and intracranial pressure control for optimizing cerebral perfusion, neuroprotection during temporary arterial occlusion, monitoring of cerebral ischemia, and recent techniques for controlling bleeding. Keywords: Intraoperative aneurysm rupture; Anesthetic management; Intracranial aneurysm; Surgical clipping

Delayed intraoperative rupture of clipped aneurysm during the awaking from anaesthesia

Introduction. Intraoperative rupture (IOR) of an aneurysm is a frightful complication that causes significant morbidity and mortality worldwide. IOR can be attributed to various parameters, including hypertension, increased intracranial pressure (ICP), fragility of the vessels, and inadequate anaesthesia. IOR due to insufficient anaesthesia is scarcely reported in the literature. Here, we describe a re-ruptured anterior communicating artery (ACoA) after incomplete clipping of the neck during craniotomy closure due to unintended early wake-up from anaesthesia with a discussion about the management. Case description. A 38-year-old male suddenly developed a severe headache, a brief loss of consciousness, and vomiting. Computed tomography (CT) scan showed a subarachnoid haemorrhage in the basal cistern. CT angiography showed a bilobed right ACoA aneurysm with a wide neck and Murphy's teat. The patient was considered for surgery. Clipping of the aneurysm neck was done through two curved clips. During craniotomy closure, the patient started coughing and gagging then a huge IOR was encountered. These events can be mainly attributed to unintended inadequate anaesthesia, particularly muscle relaxants. The bleeding ceased after two suction catheters were inserted, temporary clips were applied, and the readjustment of permanent clips. After surgery, the patient showed a left-sided weakness. His postoperative CT scan showed a right distal anterior cerebral artery (ACA) territory infarction. The weakness improved in the follow-up period. Conclusion. Delayed IOR due to early awaking from anaesthesia should be considered a potential source of complications and bad outcomes in aneurysm surgery.

Management of brain aneurysm neck-avulsion during clipping surgery

Background. Intra-operative rupture (IOR) of intracranial aneurysms is a critical event affecting the operation course and the patient’s outcome. However, A rupture induced by an avulsion in the aneurysmal neck is exceedingly challenging, as sealing the neck tear by clip application might result in ischemic injury due to parent vessel occlusion. Here we reviewed the literature regarding the intraoperative avulsion of the aneurysmal neck with an illustrative case to provide explanations of its surgical management intricacies. Methods. A Midline PubMed literature review was performed using the following keywords; (Aneurysm) AND (neck) AND (surgery or clipping) AND (tear OR avulsion). Fifty-three results were found initially. After excluding non-human subject studies, and non-English studies, two independent researchers examined the title and the abstract for the cases of neck tear or avulsion with its management. Results. Fourteen articles were found to be included in this study. The average age of the cases is around 57 years. The percentages of females in the review were 62% (8/13), and among the males, 38% (5/13). Regarding the locations, PcomA and AcomA were both 23% (3/13) of the cases; other locations include ACA, 15%, and MCA, 15%. The surgical techniques that opted from the literature include the cotton clip method, clip wrapping, parallel clipping and micro-suturing Conclusion. IOR due to aneurysmal neck avulsion is a devastating surgical complication, and its management may differ according to the extent of the rupture. Choosing the most convenient technique depends on the surgeon’s knowledge and experience.

First-in-human trial of Center Wire for neuroendovascular therapy to avoid guidewire-related complications.

An exchange maneuver is useful for the delivery of devices to target vessels. However, hemorrhagic complications can occur due to vessel perforation during an exchange maneuver. In addition, the exchange is often challenging due to unfavorable anatomy. Center Wire is an exchange-length wire with a nondetachable stent that was developed to improve navigation and stability during exchange maneuvers. The aim of this study is to investigate the safety and efficacy of Center Wire of the anchor wire technique during neuroendovascular treatment. Ten patients with intracranial aneurysms were treated after signing a Certified Review Board-approved consent. Anchor wire technique was used in all patients to navigate catheters to the target vessel for aneurysm treatment. Anchor wire technique was successfully applied in all 10 cases using Center Wire. One device-related incident of vasospasm occurred which was asymptomatic. No device-related dissection, perforation, or thromboembolic events occurred. One patient had intraoperative aneurysm rupture during coil placement which was treated immediately without clinical consequences. Two patients had postoperative ischemic strokes due to thrombotic occlusion of branches originating from the aneurysm which were unrelated to the device. This first-in-human trial of Center Wire demonstrated the safety and efficacy of the anchor wire technique for neuroendovascular treatment in a strictly regulated prospective registry trial.

Supraorbital vs pterional keyhole for anterior circulation aneurysms: A systematic review and meta-analysis

BackgroundThe supraorbital approach is a modification of the traditional pterional approach, and it offers the benefits of a shorter skin incision and a smaller craniotomy than the pterional approach. The purpose of this systemic review study was to compare the two surgical approaches for raptured and unruptured anterior cerebral circulation aneurysms. MethodsWe searched PubMed, EMBASE, Cochrane Library, SCOPUS, and MEDLINE, up to August 2021, for published studies on the supraorbital vs pterional keyhole approach for anterior cerebral circulation aneurysms, and reviewers performed a brief qualitative descriptive analysis of both approaches. ResultsFourteen eligible studies were included in this systemic review. Results indicated that the supraorbital approach for anterior cerebral circulation aneurysms had fewer ischemic events compared to pterional approach. However, no significant difference between both groups in terms of complications such as intraoperative aneurysm rupture, brain hematoma, and postoperative infections for ruptured aneurysms. ConclusionThe meta-analysis suggests that the supraorbital method for clipping anterior cerebral circulation aneurysms might be a viable alternative to the traditional pterional method as the supraorbital group had decreased ischemic events compared to the pterional group, however, the associated difficulties in utilizing this approach among ruptured aneurysms with cerebral oedema and midline shifts further needs to be understood.

Shifted-windows transformers for the detection of cerebral aneurysms in microsurgery

PurposeMicrosurgical Aneurysm Clipping Surgery (MACS) carries a high risk for intraoperative aneurysm rupture. Automated recognition of instances when the aneurysm is exposed in the surgical video would be a valuable reference point for neuronavigation, indicating phase transitioning and more importantly designating moments of high risk for rupture. This article introduces the MACS dataset containing 16 surgical videos with frame-level expert annotations and proposes a learning methodology for surgical scene understanding identifying video frames with the aneurysm present in the operating microscope’s field-of-view.MethodsDespite the dataset imbalance (80% no presence, 20% presence) and developed without explicit annotations, we demonstrate the applicability of Transformer-based deep learning architectures (MACSSwin-T, vidMACSSwin-T) to detect the aneurysm and classify MACS frames accordingly. We evaluate the proposed models in multiple-fold cross-validation experiments with independent sets and in an unseen set of 15 images against 10 human experts (neurosurgeons).ResultsAverage (across folds) accuracy of 80.8% (range 78.5–82.4%) and 87.1% (range 85.1–91.3%) is obtained for the image- and video-level approach, respectively, demonstrating that the models effectively learn the classification task. Qualitative evaluation of the models’ class activation maps shows these to be localized on the aneurysm’s actual location. Depending on the decision threshold, MACSWin-T achieves 66.7–86.7% accuracy in the unseen images, compared to 82% of human raters, with moderate to strong correlation.ConclusionsProposed architectures show robust performance and with an adjusted threshold promoting detection of the underrepresented (aneurysm presence) class, comparable to human expert accuracy. Our work represents the first step towards landmark detection in MACS with the aim to inform surgical teams to attend to high-risk moments, taking precautionary measures to avoid rupturing.

Endovascular intervention vs. microsurgery on the prognosis of anterior circulation blood blister-like aneurysm: A cohort study.

There are no universally acknowledged standardized treatment strategies for blood blister-like aneurysms (BBAs). This study compared the prognosis of patients with BBA who underwent craniotomy microsurgery vs. endovascular intervention. This retrospective cohort study included patients with BBA treated between September 2009 and August 2020 at Sichuan Provincial People's Hospital affiliated to the Sichuan Academy of Medical Science. Patients were divided into the microsurgery and endovascular groups. The preoperative Hunt-Hess grade and modified Fisher grade were collected. The intraoperative and postoperative complications (including intraoperative aneurysm rupture and hemorrhage, postoperative cerebral hemorrhage, and BBA recurrence) were recorded. Seventy-two patients were included: 28 and 44 in the microsurgery and endovascular groups, respectively. Only the preoperative Fisher grade was different between the two groups (P = 0.041). The proportion of patients with good outcomes was lower in the microsurgery group (28.6%) than in the endovascular group (72.7%), and the mortality rate was higher in the microsurgery group (32.1%) than in the endovascular group (11.4%) (P < 0.05). After adjustment for the modified Fisher grade, the multivariable analysis showed that compared with craniotomy microsurgery, an endovascular intervention was associated with the prognosis of patients with BBA (OR = 0.128, 95%CI: 0.040-0.415, P < 0.001). The rate of complications (intraoperative hemorrhage, cerebral infarction, and recurrence) was higher in the microsurgery group than in the endovascular group. In patients with BBA, an endovascular intervention appears to be associated with a better prognosis compared with craniotomy microsurgery.

Endoscopic clipping of an anterior communicating artery aneurysm.

Anterior communicating artery aneurysms are most prone to rupture. Surgically, they are conventionally being managed by a pterional approach. Some neurosurgeons prefer a supraorbital keyhole approach in select cases. Fully endoscopic clipping of such aneurysms is seldom described. We clipped an antero-inferiorly directed anterior communicating artery aneurysm endoscopically via a supraorbital keyhole approach. The intraoperative aneurysmal rupture was also managed endoscopically. The patient made an excellent postoperative recovery without any neurological deficits. Select cases of anterior communicating artery aneurysms can be clipped endoscopically using standard instruments and adhering to the basic principles of aneurysm clipping.

Surgical treatment of intracranial aneurysms in acute period of hemorrhage in Hunt-Hess grade IV-V patients at Burdenko Neurosurgical Center between 2006 and 2020

Management of patients in acute period of aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V is still a complex and unsolved problem, especially regarding surgical treatment and various complications. To analyze postoperative outcomes in patients undergoing surgery in acute period of aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V between 2006 and 2020, as well as to assess various factors influencing treatment outcomes. We analyzed 163 patients who underwent surgery within 21 days after aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V. All patients were divided into 2 groups depending on the period: 2006-2011 (group 1) and 2012-2020 (group 2). Mortality reduced from 28.6% in group 1 to 8.3% in group 2. At the same time, incidence of vegetative state (GOS grade 2) increased from 4.8% to 17.4%. Incidence of outcomes GOS grade 3 - 5 was similar. Large or giant aneurysm, repeated preoperative subarachnoid hemorrhage, intraoperative aneurysm rupture and prolonged temporary clipping can impair postoperative outcomes in patients with hemorrhage Hunt-Hess grade IV-V. External ventricular drainage, intraarterial injection of verapamil, intracisternal administration of calcium channel blockers and active surgical tactics improve postoperative outcomes and reduce mortality.

Management of Intraoperative Rupture of Intracranial Aneurysms: Agony and Ecstasy.

Intraoperative rupture (IOR) of an intracranial aneurysm is a serious complication, often with catastrophic consequences that are difficult to manage even by the best hands. Like most surgical complications, this one is better to avoid than to treat, but any vascular neurosurgeon should know how to deal with IOR of an aneurysm, because it is bound to occur. The aims of this study were to evaluate the incidence and factors associated with IOR during clipping of intracranial aneurysms, to analyze strategies for controlling hemorrhage in such cases, and to assess outcomes. Overall, 911 cases of intracranial aneurysms, which were treated surgically by the author during 26years of his professional career, were reviewed. IOR was never noted during clipping of an unruptured intracranial aneurysm (65 cases) but was encountered in 49 of 846 cases (5.8%) presenting with subarachnoid hemorrhage. This complication occurred most often in cases of internal carotid artery aneurysms (22 cases; 45%), followed by anterior communicating artery aneurysms (12 cases; 24%), distal anterior cerebral artery aneurysms (6 cases; 12%), middle cerebral artery aneurysms (6 cases; 12%), and posterior circulation aneurysms (3 cases; 6%). IOR was mostly encountered during early surgery (within 3days) after the ictus (26 cases; 53%) and most frequently occurred during dissection of the aneurysm (26 cases; 53%). Overall, 22 patients (45%) had good outcome, 18 (37%) had variable morbidity, and 9 (18%) died. Fatal consequences of IOR were noted only in cases of big or multilobulated internal carotid artery aneurysms. Detailed planning of the surgical procedure, application of meticulous microdissection techniques, and anticipation of possible intraoperative incidents during intervention aimed at clipping of an intracranial aneurysm can reduce the risk of IOR, as well as the associated morbidity and mortality.

Emerging anesthesia techniques for managing intraoperative rupture of cerebral aneurysms.

Budiansky, Adele S. MD, FRCPCa; Hjartarson, Emma P. MDb; Polis, Tomasz MD, FRCPCa; Krolczyk, Gregory MD, FRCPCa; Sinclair, John MD, FRCSCc Author Information

Endovascular treatment of «mirror» aneurysms of the middle cerebral artery

Objective ‒ to analyze the results of endovascular treatment of the «mirror» MCA aneurysms.Materials and methods. A retrospective analysis of the 172 patients with multiple cerebral aneurysms, who were treated between the period from April 2016 to February 2022 at Scientific and Practical Center of Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine was conducted. «Mirror» MCA aneurysms were found in 20 (11.6 %) patients. Twenty patients had 54 aneurysms (8 patients had 12 aneurysms except MCA and 2 patients had 2 MCA aneurysms at one side). In one patient, a combination of «mirror» aneurysms of MCA and internal carotid artery was found. The group included 8 (40 %) men and 12 (60 %) women. The average age of the patients was (47.11 ± 11.73) years; range 23‒64 years. 8 (40 %) patients had subarachnoid hemorrhage due to MCA aneurysm rupture, in another 3 (15 %) patients another aneurysm was the cause of rupture, and 9 (45 %) of patients underwent surgery for unruptured aneurysms. The choice of treatment strategy and its staging, peri-procedural (bleeding, migration of coils, thrombus formation) and postoperative complications and the result of the treatment at the time of discharge and 3–6 months after the final treatment were analyzed. Qualitative assessment of aneurysm occlusion was performed intraoperatively and during follow-up angiographic examinations according to the modified Raymond‒Roy scale.Results. Of all 54 aneurysms in 20 patients, 49 aneurysms (40 MCA aneurysms and 9 aneurysms in other localization) were excluded endovascularly, 1 MCA aneurysm was clipped, and 4 aneurysms due to their small size were left for observation with regular follow-up examinations due to the low risk of rupture. Bilateral one-session endovascular occlusion of the «mirror» MCA aneurysms was performed in 11 patients, and staged procedure was performed in 9. Among 40 surgically treated «mirror» MCA aneurysms, 24 (60 %) were excluded with only coiling, 7 (17.5 %) with stent assistance coiling, 7 (17.5 %) with balloon assistance coiling, 1 aneurysm (2.5 %) was treated with parent artery occlusion, and 1 aneurysm (2.5 %) was clipped. Intraoperative complications occurred in 2 patients. One patient had an intraoperative rupture of an ICA aneurysm combined with «mirror» MCA aneurysms, which could not be stopped and ICA sacrifice was performed. In another, the coils migrated into the artery. In the first patient, the course of the disease was complicated with brain infarction in the left ICA region. Another patient was prescribed antiplatelet therapy in postoperative period, which was uneventful. Follow-up angiography studies were available in 16 patients. At the follow-up examination, significant recanalization of one of the MCA aneurysm was detected in two patients, who were successfully occluded during the second procedure without negative clinical outcome. In 15 patients at the control examination, the evaluation of the result according to the mRS was 1 – 2 points, and in 1 patient ‒ 3 points.Conclusions. Our series demonstrates that the outcomes of endovascular treatment of the «mirror» MCA aneurysms have comparable risks of periprocedural and post-procedural complications, with the general population of patients with both ruptured and unruptured MCA aneurysms. Best treatment strategy must be individualized with careful planning, considering which aneurysm should be excluded first, the possible sequence of treatment, depending on the clinical presentation, type of intervention, age, patient preference and available options. It is also necessary to assess the traumatic nature of treatment methods. In our opinion, endovascular interventions have obvious advantages over bilateral craniotomies or extended combined unilateral approaches, which in turn has the potential to improve the results of treatment, both in the short and long term, and to reduce its duration and cost.