Postoperative Vasospasm Research Articles

Minimally invasive keyhole craniotomies for microsurgical clipping of cerebral aneurysms: comparative meta-analysis of the mini-pterional and supraorbital keyhole approaches.

Axel Perneczky is responsible for conceptualizing the "keyhole" philosophy as a new paradigm of minimal invasiveness within cranial neurosurgery. Keyhole neurosurgery aims to limit approach-related traumatization and minimize brain retraction while still enabling the neurosurgeon to achieve operative goals. The supraorbital keyhole craniotomy (SOKC) and minipterional (pterional keyhole, PKC) approaches have become mainstays for clipping intracranial aneurysms. While studies have compared these approaches to the traditional pterional craniotomy for clipping cerebral aneurysms, head-to-head comparisons of these workhorse keyhole approaches remain limited. The authors queried three databases per PRISMA guidelines to identify all studies comparing the SOKC to the PKC for microsurgical clipping of cerebral aneurysms. Of 148 unique studies returned on initial query, a total of 5 studies published between 2013 and 2019 met inclusion criteria. Where applicable, quantitative meta-analysis was performed via the Mantel-Haenszel method using Review Manager v5.4 (Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Risk of bias (ROB) was assessed using the Cochrane ROBINS-I tool, and all studies were assigned a Level of Evidence (I-V). Across all five studies, the mean age ranged from 53.0 to 57.5 years old, and the cohort consisted of more females (n = 403, 60.6%) than males. The proportion of patients presenting with ruptured aneurysmal SAH was comparable between the SOKC and PKC cohorts (p = 0.43). Clipping rate [defined as the rate of successful aneurysm clip deployment with successful intraoperative occlusion] (OR 1.52 [0.49, 4.71], I2 = 0%, p = 0.47), final occlusion rates (OR 1.27 [0.37, 4.32], p = 0.70), and operative durations (SMD 0.33 [-0.83. 1.49], I2 = 97%, p = 0.58) were comparable regardless of approach used. Furthermore, rates of intraoperative rupture (OR 1.51 [0.64, 3.55], I2 = 0, p = 0.34), postoperative hemorrhage (OR 1.49 [0.74, 3.01], I2 = 0, p = 0.26), postoperative vasospasm (OR 0.94 [0.49, 1.80], I2 = 63, p = 0.86), and postoperative infection (OR 0.70 [0.16, 2.99], I2 = 0%, p = 0.63) were equivocal across SOKC and PKC cohorts. The PKC and SOKC approaches appear to afford comparable outcomes when used for open microsurgical clipping of cerebral aneurysms in select patients with both ruptured and unruptured aneurysms. Both are associated with excellent clipping and occlusion rates, minimal perioperative complication profiles, and favorable postoperative neurologic outcomes. Further investigations are merited so clinicians can further parse out the indications and contraindications for each keyhole approach.

Anterior Communicating Artery Aneurysms: Surgical Strategy and Outcome based on Proposed Newer Classification

Background: The ruptured anterior communicating artery aneurysm is the most frequent intra-cranial aneurysm treated at any neurosurgical department. These aneurysms arise from either the A1-A2-Acom artery junction or Acom artery. The surgical outcome depends on the age of the patient, time duration between ictus and surgery, and Hunt and Hess grade at admission. In this article, we intend to analyze the surgical outcome based on our proposed classification with our overall experience of Acom aneurysm. Methods: A retrospective review of our surgical database with 250 patients of ruptured Acom was done, and the location, morphology, and direction of aneurysm, along with other clinical parameters including the demographic profile, radiological findings, and intra-operative details, were studied. We classified the Acom based on both site of origin and morphology (Type I, junctional on the dominant side; Type II, fusiform with an ill-defined neck and branching pattern; Type III, saccular true Acom A) and secondarily as described in the literature on the basis of the direction of fundus (Type A–E). The clinical parameters were compared among the above groups using Fischer-exact and one-way analysis of variance test. Results: A total of 250 patients (M: F =113:137) were included (mean age 52.1 ± 11.5 standard deviation years). 55.2% patients had left A1 dominance. Type I Acom A was commonly found on the left dominant circulation (P = 0.00). The difference in aspect ratio of Type I (2.0 ± 0.8) and Type II (1.8 ± 0.52) aneurysms was insignificant (P = 0.28). However, a significant difference in post-operative vasospasm among different types of aneurysms was found (P < 0.05). The Type I Acom A were anteriorly directed, while Type II and III were posteriorly directed (P = 0.001). The mean follow-up of the study was 44.4 ± 25.7 months, with age (P = 0.007) and Hunt and Hess grade (P = 0.001) at admission correlating with surgical outcome. Conclusion: Classifying the Acom A pre-operatively based on site and morphology, location, and direction of fundus helps in surgical planning and prognosis. The junctional ‘Type IA aneurysms’ are most common and possess a high intra-operative rupture rate. The anteriorly directed aneurysms have a better prognosis, and visual complaints are usually associated with anterior-inferiorly directed aneurysms.

Hypotension and Bradycardia Following Papaverine Installation During Intracranial Aneurysm Surgery: A Report of Three Cases

Abstract Introduction One of the major complications of intracranial aneurysm surgery is vasospasm. Papaverine is an effective vasodilator that can be instilled directly onto the vessels in the operative field with the aim of preventing intraoperative and postoperative vasospasm. Several case reports of hemodynamic instability in general and of hypotension, in particular, were reported after the use of topical papaverine during aneurysm clipping surgery. Case description Herein, we report three cases of transient profound hypotension and relative bradycardia after intracisternal papaverine usage during ruptured anterior communicating artery aneurysm clipping surgery. Conclusion Caution should be taken while using papaverine intracisternally during anterior circulation aneurysm clipping, since it may cause several serious complications, including profound hemodynamic instability, particularly when instilling on a fenestrated lamina terminalis.

Management of postoperative cerebral vasospasm in skull base surgeries: A systematic review of case reports and series.

This study provides a comprehensive overview of the management of postoperative vasospasm after skull base surgeries. This phenomenon is rare but can be of serious sequelae. Medline, Embase, and PubMed Central were searched, along with examining the references of the included studies. Only case reports and series that reported vasospasm following a skull base pathology were incorporated. Cases with pathologies other than skull base, subarachnoid hemorrhage, aneurysm, and reversible cerebral vasoconstriction syndrome were excluded from the study. Quantitative data were presented as mean (Standard Deviation) or median (range), accordingly, while qualitative data were presented as frequency (percentage). Chi- square test and one-way analysis of variance were used to assess for any association between the different factors and patient outcomes. We had a total of 42 cases extracted from the literature. The mean age was 40.1 (±16.1) with approximately equal males and females (19 [45.2%] and 23 [54.8%], respectively). The time to develop vasospasm after the surgery was 7 days (±3.7). Most of the cases were diagnosed by either angiogram or magnetic resonance angiography. Seventeen of the 42 patients had pituitary adenoma as the pathology. Anterior circulation was nearly affected in all patients. For management, most patients received pharmacological with supportive management. Twenty-three patients had an incomplete recovery as a result of vasospasm. Vasospasm following skull base operations can affect males and females, and most patients in this review were middle-aged adults. The outcome of patients varies; however, most patients did not achieve a full recovery. There was no correlation between any factors and the outcome.

Results of surgical treatment of patients with ruptured anterior communicating artery aneurysms

Anterior communicating artery aneurysms (AComA) are the most common type of intracranial aneurysms, accounting for approximately 35 % of all ruptured intracranial aneurysms.
 The aim of this study was to evaluate the results of surgical treatment of patients with ruptured AComA aneurysms.
 Materials and methods. The study included 98 patients who underwent surgical treatment for ruptured AComA aneurysms between 2008 and 2019 at the Uzhhorod Regional Center of Neurosurgery and Neurology and CNE “Сity Hospital of Emergency and Urgent Medical Care” of Zaporizhzhia City Council. The mean age of the patients was 47.8 ± 11.0 years, and 51.0 % were female.
 Results. Upon admission to the hospital, 69.3 % of patients with ruptured AComA aneurysms were conscious. The level of consciousness was influenced by the presence and size of an intracerebral hematoma, the severity of intraventricular blood circulation due to its presence, and the prevalence of angiospasm. Aneurysms of average size (6–15 mm according to the classification of G. Yasargil, 1984) were found in 44.9 % of cases.
 Postoperative mortality was 11.2 %. Postoperative vasospasm was the most common complication, occurring in 51.0 % of the patients. A good outcome in accordance with the modified Rankin Scale (mRS) was achieved in 66.3 % of the patients.
 Conclusions. Surgical treatment remains an effective treatment for ruptured AComA aneurysms, with favorable outcomes, which depend on age, serious condition of the patient, level of consciousness, re-rupture of the aneurysm, timing of the surgical operation, presence and size of intracerebral hematoma, presence and intensity of intraventricular hemorrhage, presence and intensity of angiospasm.

PRE-OPERATIVE LUMBAR DRAINAGE VERSUS NO LUMBAR DRAINAGE IN PATIENTS UNDERGOING CLIPPING FOR RUPTURED ANEURYSMAL INTRACRANIAL BLEED

Aim:. To compare effectiveness of Pre-operative lumbar drainage and Non- Lumbar Drainage in surgical dissection of ruptured intra-cranial aneurysm. A prospective, ran Materials and methods:. domized, comparative study was conducted on 50 patients of aneurysmal SAH in the departmemt of neurosurgery starting from January 2020. Patients with deranged coagulation prole, meningitis contradicting placement of intra-thecal drain, infection at lumbar region and patients not giving consent were excluded. Patients were randomly assigned to two group A and group B. Patients of group A were subjected to clipping of aneurysm with Pre-operative lumbar drain placement after induction of anaesthesia and patients ofgroup B were subjected to clipping of aneurysm without lumbar drainage. Results Ÿ Post-operative vasospasm- The post-operative vasospasm was present in 24.0% of the cases of lumbar drain group and 52.0% of the cases without lumbar drain group which was statistically signicant. Ÿ Post-operative early infarct -Post-operative early infarct was present in 8.0% of the cases in lumbar drain group and 32.0% of the cases without lumbar drain group which was statistically signicant. Ÿ Post-operative late infarct- The post-operative late infarct was present in 4.0% of the lumbar rain group and 24.0% of the patients without lumbar drain group which was statistically signicant Ÿ Post-operative ICU stay- Post-operative ICU stay was less than or equal to 7 days in 84.0% of the cases in lumbar drain group and 56.0% of the without lumbar drain group which was statistically signicant Ÿ On discharge motor decit- On discharge motor decit was present in 20.0% of the cases in lumbar drain group and 24.0% of the cases in without lumbar drain group which was not statistically signicant Conclusions: This study was undertaken mainly to study the efcacy of lumbar drainage in management of ruptured aneurysm with SAH. This study had shown that, the lumbar drain was useful in preventing the vasospasm, early and late infarct. The number of days of stay in ICU was also lower in lumbar drain group than the control group. In addition lumbar drain does provide help to surgeon in surgical dissection of sylvian ssure as well as dissection around aneurysm

Initial Experience Using the Transradial Approach for Endovascular Treatment of Vascular Pathologies: Safety and Feasibility.

Background Endovascular treatment of vascular pathologies through the transradial approach has been increasingly used and has demonstrated a low rate of complications. Objective To report our initial experience in the endovascular treatment of cerebrovascular diseases with the transradial approach and to determine its safety and feasibility. Methods Consecutive patients who underwent the transradial approach for endovascular treatment of aneurysms and vascular malformations were reviewed at a single institution. Technical success, fluoroscopy time, and access-related complications were analyzed. Results Eight patients underwent endovascular treatment with the transradial approach. One arteriovenous fistula, one superficial temporal artery aneurysm, three arteriovenous malformations, and four aneurysms were treated successfully. The radial artery was successfully approached and a 6-F sheath was used in all the cases. Navigation of guiding catheters (5 and 6 F) was done without complications. The most commonly approached artery was the right internal carotid artery, followed by the right vertebral artery. Postoperative vasospasm was identified in three patients. Mean fluoroscopy time was 34.7 minutes. Conversion to transfemoral approach was not required. No postoperative complications were reported. Conclusions In our initial experience, the transradial approach is a safe and feasible alternative for the endovascular treatment of cerebrovascular pathologies.

Comparison of Blister Aneurysm Treatment Techniques: A Systematic Review and Meta-Analysis

Blood blister aneurysms are small, thin-walled, rapidly growing side-wall aneurysms that have proved particularly difficult to treat, and evidence-based guidance for treatment strategies is lacking. A systematic review and meta-analysis was performed to aggregate the available data and compare the 3 primary treatment modalities. We performed a comprehensive literature search according to PRISMA guidelines followed by an indirect meta-analysis that compares the safety and efficacy of surgical, flow-diverting stents (FDS), and other endovascular approaches for the treatment of ruptured blood blister aneurysms. A total of 102 studies were included for quantitative synthesis, with sample sizes of 687 treated surgically, 704 treated endovascularly without FDS, and 125 treated via flow diversion. Comparatively, FDS achieved significantly reduced rates of perioperative retreatment compared with both surgical (P= 0.025) and non-FDS endovascular (P < 0.001). The FDS subgroup also achieved a significantly lower incidence of perioperative rebleed (P<0.001), perioperative hydrocephalus (P= 0.012), postoperative infarction (P= 0.002), postoperative hydrocephalus (P < 0.001), and postoperative vasospasm (P= 0.002) compared with those patients in the open surgical subgroup. Although no significant differences were found among groups on the basis of functional outcomes, angiographic outcomes detailed by rates of radiographic complete occlusion were highest for surgical (90.7%, 262/289) and FDS (89.1%, 98/110) subgroups versus the non-FDS endovascular subgroup (82.7%, 268/324). Flow diversion seems to be an effective treatment strategy for ruptured blood blister aneurysms, with lower rates of perioperative complications compared with surgical and other endovascular techniques, but studies investigating long-term outcomes after flow diversion warrant further study.

CEREBRALANEURYSM SURGERY IN A PATIENT WITH CHRONIC RENAL FAILURE: PERIOPERATIVE CONCERNS AND CONFLICTS

Chronic renal failure (CRF) and associated multi-system abnormalities can adversely impact the outcome in patients undergoing high-risk aneurysm surgeries by causing hemodynamic instability, uid-electrolyte imbalance, bleeding and coagulation abnormalities, decreased anesthetic drug excretion, and dialysis-related complications. Conicts between the standard perioperative practices in aneurysm surgery and those in CRF further contribute to the management challenges. These include, using low anesthetic drug doses but achieving good brain relaxation, using a restrictive uid therapy but preventing postoperative vasospasm, and avoiding diuretics causing nephrotoxicity but reducing intracranial pressure. Ayoung male with dialysis-dependent CRF and hypertension underwent emergency craniotomy and clipping of a cerebral aneurysm. He was managed with a modied protocol of reduced heparin hemodialysis, BIS-guided use of minimum anesthetic drugs, goal-directed optimum uid therapy, maintaining hemodynamic stability, and management of post-aneurysm clipping vasospasm with hypertension. His perioperative management and related conicts are discussed

Application of MRI images based on Spatial Fuzzy Clustering Algorithm guided by Neuroendoscopy in the treatment of Tumors in the Saddle Region.

Objective:The paper applies spatial fuzzy clustering algorithm to explore the role and value of neuroendoscopic assisted technology in the operation of tumors in the saddle region, and analyze the MRI image characteristics of tumors in the saddle region.Methods:The clinical data of 63 patients from our hospital who underwent neuroendoscopic assisted microscopy to remove tumors in the saddle area from 2017 to 2019 (neuroendoscopy-assisted group) were collected. Seventy six patients who occupied the saddle area by microscopic resection only in the same period (Simple microscope group) clinical data. By comparing the patient’s tumor resection rate, postoperative complication rate and postoperative recurrence rate, the surgical effect was evaluated.Results:The total resection rates of the tumors in the neuroendoscopy-assisted group and the microscope-only group were 95.24% (60/63) and 80.26% (61/76). The incidence of postoperative vasospasm was 3.17% (2/63) and 13.16% (10/76), the incidence of nerve injury was 0 (0/63) and 6.58% (5/76), the difference was statistically significant (P <0.05). There was no significant difference in the incidence of postoperative infection, cerebrospinal fluid leakage and postoperative recurrence rate between the two groups (P> 0.05).Conclusion:Neuroendoscopy-assisted microscopy-based removal of the saddle area occupying space based on spatial fuzzy clustering algorithm can increase the total tumor resection rate and reduce the incidence of complications.

Comparison of transradial and transfemoral cerebral angiography

ObjectivesTo compare the feasibility, safety and effectiveness of transradial and transfemoral artery puncture cerebral angiography. MethodsThe clinical data of 30 cases (radial artery group) and 256 cases (femoral artery group) of cerebrovascular angiography through radial artery puncture were retrospectively analyzed, and the puncture success rate, angiography time, exposure time and surgical complication rate were compared. ResultsThere was no significant difference in the success rate of puncture between the two groups (P > 0.05). The procedure time and radiation exposed time were longer than those in the femoral artery group (P < 0.05). The incidence of hematoma in the radial artery group was lower than femoral artery group (P < 0.05), but the incidence of vasospasm was higher than femoral artery group (P < 0.05). ConclusionCompared with traditional angiography through femoral artery puncture, the procedure time and duration of angiography through radial artery puncture were slightly longer, and the incidence of postoperative vasospasm was slightly higher, but the trauma was small, the incidence of hematoma at puncture site was low, and the patients did not need to stay in bed, which were applicable to patients with different needs.

Impact of early surgery of ruptured cerebral aneurysms on vasospasm and hydrocephalus after SAH: Our preliminary results

objectiveTiming of surgical treatment of ruptured intracranial aneurysms has undergone a drastic change in the last few decades with preference for early surgeryOur paper focuses specifically on the prognostic importance of timing of surgery, since early surgery of ruptured aneurysms provides immediately good clinical results.We present a series of cases operated in early and ultra early surgery, evaluating the technical aspects, the efficacy, the safety and the clinical results. Patients and MethodsWe retrospectively reviewed the clinical records and radiological imaging of patients treated for ruptured intracranial aneurysms who underwent early and ultra early clipping between January 2011 and April 2017 at our Institution. We included patients treated within the first 12 h and subsequently we divided our series in two subgroups based on the timing of surgery comparing the “early surgery” group (within 12 h) with the “ultra early surgery” group (within 6 h). ResultsSeventy-six (76) patients undergoing either early or ultra-early surgery for ruptured intracranial aneurysms have been reportedEither early or ultra-early surgery showed a statistically favorable impact on reducing the incidence of both postoperative vasospasm and hydrocephalus. Ultra-early surgery group had the best outcome at the statistical analyses. (good postoperative 1Y GOSE.) ConclusionsWe strongly believe that patients affected by ruptured intracranial aneurysms excluding Hunt and Hess grade V patients) should be treated as soon as possible and hence it should be considered as an emergency surgery.This approach prevents immediately a second bleeding of the aneurysm, allows to treat any associated condition of intracranial hypertension including hematomas and hydrocephalus and to use safely aggressive medical therapy such as hypertension.

Surgical Intervention of Intracerebral Hematoma Caused by Ruptured Middle Cerebral Artery Aneurysm in Neurosurgery Teaching Hospital, Baghdad, Iraq.

The incidence of intracerebral hematoma among patients with aneurysmal subarachnoid hemorrhage is up to third of the cases (12%-35%). The presence of an aneurysm with ICH negatively influences the patient's presentation, course, and outcome, and may be associated with an increased re-hemorrhage rate, vasospasm, cerebral edema, and hydrocephalus. Aneurysm obliteration and hematoma evacuation have been associated with a favourable outcome. To explore the effectiveness and the prognostic factors for patients with middle cerebral artery aneurysm associated with intracerebral hematoma treated by early surgical clipping of the aneurysm with hematoma evacuation. We analysed 21 patients with intracerebral hematoma caused by ruptured middle cerebral artery aneurysm presented to the Neurosurgery teaching hospital from January 2017 to January 2019. Parameters included five broad categories: demographic, clinical, radiological, surgical, and outcome. We found the following factors significantly related with unfavorable patient outcome: Preoperative cranial nerves deficit, dysphasia, severe contralateral weakness, presence of dilated ventricles in CT scan, presence of IVH in CT scan, aneurysm location in the dominant (left) hemisphere, high modified-Fisher grade, duration of surgery more than six hours, occurrence of intraoperative aneurysm rupture, poor postoperative GCS, occurrence postoperative vasospasm, more severe postoperative contralateral weakness, and the presence of postoperative seizure. While the good initial GCS and early surgery significantly related to favourable patient outcome. Early surgical intervention of intracerebral hematoma caused by ruptured middle cerebral artery aneurysm has a favourable outcome in general and should be supported with consideration of the significant prognostic factors for each patient before the commencement of the surgery.

A pilot study on assessing the role of intra-operative Flow 800 vascular map model in predicting onset of vasospasm following micro vascular clipping of ruptured intracranial aneurysms

Objective To ascertain the predictive value of intra-operative FLOW 800 vascular map model in predicting onset of post-operative clinical vasospasm and delayed cerebral ischemia among patients undergoing micro-vascular clipping of ruptured intracranial aneurysms. Material and methods A total of 40 patients were enrolled in the study and their variables such as age, World Federation of Neurological Surgeons (WFNS) grade at presentation, Computerized Tomography (CT) Fisher grading, location of the aneurysms, and Indocyanine Green (ICG) flow status were compared and statistically analyzed along with differences in Absorption Intensities (AI) and difference in time lag values obtained from the FLOW 800 vascular map studies for predicting onset of vasospasm. Results The Receiver Operating curve (ROC) of the model for predicting post-operative vasospasm was highest (.892) for difference in the AI followed by CT Fisher grading (.778), difference in time lag (.700) and WFNS grading (.699).Analysis of variance for different variables studied in our model for predicting vasospasm was significant for all except for age (.991) and the ICG flow through the parent vessel (.079).Multivariate analysis done for predicting the vasospasm was significant for all variables except for age (.869) and ICG main flow (.196) Conclusion Our study confirmed the role of FLOW 800 study model in predicting clinical vasospasm. Inclusion of this entity would therefore help in taking timely and correct therapeutics measures to ensure better patient outcomes.

Effects of evidence-based nursing on the psychological status and complications after interventional embolization of intracranial aneurysms

Objective To investigate the effects of evidence-based nursing on the psychological status, operation associated complications and short-term prognosis of patients with intracranial aneurysms after interventional embolization. Methods A total of 150 patients undergoing elective interventional embolization in the hospital from May 2012 to May 2016 were randomly divided into the control group and the observation group with 75 patients each. The control group were given routine nursing care while the observation group were given evidence-based nursing. The incidence of operation associated complications and postoperative cerebral vasospasm were compared between the two groups. The changes in scores of the Self-Rating Anxiety Scale (SAS) , Self-Rating Depression Scale (SDS) , Somatization Symptom Checklist (SCL-90) and Glasgow Outcome Scale (GOS) before and after intervention were compared. Results No postoperative cerebral vasospasm was observed in the observation group, and the incidence of operative complications was 4%. In the control group, cerebral vasospasm occurred in 7 cases, and the incidence of operative complications was 17.3%. Before discharge, SAS score (42.26±3.77) and SDS score (40.67±6.44) in the observation group were lower than those in the control group (t=8.478, 4.507; P<0.001) . No death cases in these two groups. Three months later after operation, patients with GOS grade 5 in the observation group was 30.67%, and it was 13.33% in the control group. There was significant difference of GOS classification between the two groups (H=15.520, P<0.01) . Conclusions Evidence-based nursing can help reduce the incidence of cerebral vasospasm after interventional embolization in patients with intracranial aneurysms, improve their anxiety and depression, and optimize short-term prognosis. Key words: Intracranial aneurysm; Evidence-based nursing; Cerebral vasospasm; Interventional embolization

A pilot study on assessing the role of intra-operative Flow 800 vascular map model in predicting onset of vasospasm following micro vascular clipping of ruptured intracranial aneurysms.

Objective To ascertain the predictive value of intra-operative FLOW 800 vascular map model in predicting onset of post-operative clinical vasospasm and delayed cerebral ischemia among patients undergoing micro-vascular clipping of ruptured intracranial aneurysms. Material and methods A total of 40 patients were enrolled in the study and their variables such as age, World Federation of Neurological Surgeons (WFNS) grade at presentation, Computerized Tomography (CT) Fisher grading, location of the aneurysms, and Indocyanine Green (ICG) flow status were compared and statistically analyzed along with differences in Absorption Intensities (AI) and difference in time lag values obtained from the FLOW 800 vascular map studies for predicting onset of vasospasm. Results The Receiver Operating curve (ROC) of the model for predicting post-operative vasospasm was highest (.892) for difference in the AI followed by CT Fisher grading (.778), difference in time lag (.700) and WFNS grading (.699).Analysis of variance for different variables studied in our model for predicting vasospasm was significant for all except for age (.991) and the ICG flow through the parent vessel (.079).Multivariate analysis done for predicting the vasospasm was significant for all variables except for age (.869) and ICG main flow (.196) Conclusion Our study confirmed the role of FLOW 800 study model in predicting clinical vasospasm. Inclusion of this entity would therefore help in taking timely and correct therapeutics measures to ensure better patient outcomes.

Risk Factors for In-Hospital Seizures and New-Onset Epilepsy in Coil Embolization of Aneurysmal Subarachnoid Hemorrhage

This study aimed to determine risk factors for inpatient seizures and long-term epilepsy in patients receiving coil embolization for aneurysm-associated subarachnoid hemorrhage. A retrospective chart review was conducted for patients admitted to the University of Pittsburgh Medical Center from 2010 to 2014 for subarachnoid hemorrhage. Only patients with coil embolization were included. Variables such as subdural hematoma, cerebral infarction, postoperative vasospasm, cerebral edema, and mass effect were collected. After discharge, patients were followed up to determine whether epilepsy had developed. The χ2 test was used to assess univariate associations. Multivariable associations were assessed with a binary logistic regression model. The study included 175 patients, of whom 16 (9.1%) of the patients had seizures while they were inpatients. Five out of 73 patients met the criteria for epilepsy at follow-up. None of the patients with epilepsy after discharge had electrographic seizures while hospitalized. Vasospasm (odds ratio [OR] 6.88, 95% confidence interval [CI] 1.81-26.25), and Hunt and Hess grade 5 (OR 26.16, 95% CI 3.95-173.49) were significantly associated with in-hospital seizures in a multivariable analysis. Epileptiform discharges on electroencephalogram (EEG) were significantly associated with mass effect findings on brain imaging (OR 3.5, CI 1.05-11.69). Hunt and Hess grade 5 and vasospasm are independent risk factors for in-hospital seizures. In addition, mass effect is an independent risk factor for epileptiform discharges on EEG. Patients with these risk factors may benefit from continuous EEG. Our results may indicate that there is no association between electrographic seizures and development of epilepsy.

Effects of different anesthetics on recovery of neurological function after intracranial aneurysm embolization

Objective To compare the effects of different anesthetics on the recovery of neurological function after intracranial aneurysm embolization. Methods One hundred patients of both sexes with aneurysmal subarachnoid hemorrhage, aged more than 18 yr, with body mass index of 18.5-24.0 kg/m2, of American Society of Anesthesiologists physical status Ⅱ or Ⅲ and WFNS grade Ⅰ-Ⅳ, with the thickness of subarachnoid hemorrhage more than 4 cm, were divided into 2 groups (n=50 each) using a random number table: propofol group (group P) and sevoflurane group (group S). After anesthesia induction, group P received intravenous infusion of propofol 100-300 μg·kg-1·min-1, while the end-tidal sevoflurane concentration was maintained at 1.4%-3.5% in group S. Immediately before induction (T0), immediately after the end of induction (T1), immediately after successful embolization of aneurysm (T2) and at 1, 2, 3 and 5 days after surgery (T3-6), central venous blood samples were collected for determination of plasma neuron-specific enolase and S100β protein concentrations by enzyme-linked immunosorbent assay.The development of postoperative cerebral vasospasm and delayed ischemic neurological deficit was recorded.The patients were followed up, and the Glasgow outcome score and occurrence of newly developed cerebral infarction were recorded within 6 months after surgery. Results There was no significant difference in the concentrations of plasma neuron-specific enolase and S100β protein at each time point, incidence of postoperative cerebral vasospasm and delayed ischemic neurological deficit, or Glasgow outcome score and incidence of newly developed cerebral infarction within 6 months after surgery between two groups (P>0.05). Conclusion Propofol and sevoflurane exert no effect on the recovery of neurological function after intracranial aneurysm embolization. Key words: Anesthetics; Recovery of function; Intracranial aneurysm; Embolization, therapeutic

Focused opening of the Sylvian fissure for the management of middle cerebral artery aneurysms.

Background:A wide opening of the Sylvian fissure (SF) regarding the treatment of middle cerebral artery (MCA) aneurysm allows us to ensure early proximal control by the proximal start of Sylvian dissection and enough comfort for the microsurgical manipulation and aneurysm clipping. However, major mechanical manipulation of arteries associated with blood oozing into the surgical field may increase the incidence of postoperative vasospasm. The risk of Sylvian venous injury is bigger, and the damage of the superior temporal gyrus increases the risk of postoperative epilepsy as well. A focused opening of the SF based on 18 years experience of a senior author is an alternative technique we present in this video abstract.Technique:A proper preoperative planning and an image-based anatomic orientation of the Sylvian opening together with a complete understanding of the microanatomy of the clipping field are essential requirements for a proper focused SF opening. A patient with an MCA bifurcation aneurysm is placed in supine position. The head elevated 20 cm above the cardiac level is slightly extended, rotated to the contralateral side, and tilted laterally. A lateral supraorbital approach is performed. After cerebrospinal fluid release and under high magnification, the opening place of the SF is identified. Thus, 10–15 mm opening is made with a sharp needle followed by microscissors. Under a keyhole concept, the M1 segment of the MCA is recognized, and the aneurysm is carefully dissected. A temporary clipping with a proximal control of the M1 segment is followed by a definitive clipping of the aneurysm. Postoperative imaging does not show any complication.Conclusion:The focused opening of the SF is a less invasive technique for the management of MCA bifurcation aneurysms. However, some extra considerations should be taken for large or giant aneurysms in which a wide opening of the SF might be required for a proper aneurysm manipulation, and for those deep MCA bifurcation aneurysms close to the internal carotid artery bifurcation, in which an anterograde dissection of the MCA might be more suitable.Videolink:http://surgicalneurologyint.com/videogallery/focused-opening-of-the-syvian-fissure/

Delayed Complications After Transsphenoidal Surgery for Pituitary Adenomas.

Perioperative complications after transsphenoidal surgery for pituitary adenomas have been well documented in the literature; however, some complications can occur in a delayed fashion postoperatively, and reports are sparse about their occurrence, management, and outcome. Here, we describe delayed complications after transsphenoidal surgery and discuss the incidence, temporality from the surgery, and management of these complications based on the findings of studies that reported delayed postoperative epistaxis, delayed postoperative cavernous carotid pseudoaneurysm formation and rupture, vasospasm, delayed symptomatic hyponatremia, hypopituitarism, hydrocephalus, and sinonasal complications. Our findings from this review revealed an incidence of 0.6%-3.3% for delayed postoperative epistaxis at 1-3 weeks postoperatively, 18 reported cases of delayed carotid artery pseudoaneurysm formation at 2 days to 10 years postoperatively, 30 reported cases of postoperative vasospasm occurring 8 days postoperatively, a 3.6%-19.8% rate of delayed symptomatic hyponatremia at 4-7 days postoperatively, a 3.1% rate of new-onset hypopituitarism at 2 months postoperatively, and a 0.4%-5.8% rate of hydrocephalus within 2.2 months postoperatively. Sinonasal complications are commonly reported after transsphenoidal surgery, but spontaneous resolutions within 3-12 months have been reported. Although the incidence of some of these complications is low, providing preoperative counseling to patients with pituitary tumors regarding these delayed complications and proper postoperative follow-up planning is an important part of treatment planning.