Cerebral Aneurysm Surgery Research Articles

Endoscope-integrated indocyanine green video-angiography for cerebral aneurysm surgery: a more effective technique

Abstract Introduction: Microscope-integrated indocyanine green video-angiography (mICG-VA) is used as an adjunct to aneurysm surgery in checking for small compromised perforating arteries and the remnant of an aneurysmal neck. A limitation of mICG-VA is the inability to access the deep area where small vessels are located behind the aneurysm sac or the parent artery. The endoscope-integrated ICG-VA (eICG-VA) is not only a tool in obtaining a wide angle of surgical view, but also is a technique to detect real-time blood flow during aneurysm clipping. Methods: Patients with an unruptured cerebral aneurysm who had conventional endoscope-assisted microsurgery and eICG-VA were enrolled. We compared the efficacy and additional details of imaging from both types of procedures. Results: The data of seven patients were reviewed. In two cases of small perforating arteries that were hidden by the aneurysm sacs, more details were detected by eICG-VA. While the performance of the conventional technique was limited, the eICG-VA revealed a wide view in the deep area during aneurysm clipping. Conclusion: The eICG-VA provides more details of the aneurysm, especially in small perforating vessels that were hidden by the aneurysm. It can resolve the limitations of the conventional endoscope and mICG-VA.

Transfusion Frequency of Red Blood Cells, Fresh Frozen Plasma, and Platelets During Ruptured Cerebral Aneurysm Surgery

The use of blood products after subarachnoid hemorrhage (SAH) is common, but not without controversy. The optimal hemoglobin level in patients with SAH is unknown, and data on perioperative need for red blood cell (RBC), fresh frozen plasma (FFP), or platelet transfusions are limited. We studied perioperative administration of RBCs, FFP, and platelets and the impact of red blood cell transfusions (RBCTs) on outcome in patients undergoing surgery for ruptured a cerebral arterial aneurysm. A retrospective analysis was performed of 488 patients with aneurysmal SAH during the years 2006-2009 at Helsinki University Central Hospital. Patients who received RBC, FFP, or platelet concentrates perioperatively were compared with a cohort of patients from the Helsinki database of aneurysmal SAH who did not receive transfusions. A multiple regression model was created to identify factors related to transfusion and outcome. RBC, FFP, or platelet concentrates were given in 7.6% (37 of 488), 3.1% (15 of 488), and 1.2% (6 of 488) of patients intraoperatively and in 3.5% (17 of 486), 1.6% (8 of 488), and 0.9% (4 of 488) of patients postoperatively. Of 37 intraoperative RBCTs, 26 were related to intraoperative rupture of the aneurysm. Intraoperative RBCTs were associated with lower preoperative hemoglobin concentration, higher World Federation of Neurosurgical Societies classification, and intraoperative rupture of an aneurysm. In multivariate analysis, intraoperative RBCT (odds ratio = 5.13, 95% confidence interval = 1.53-17.15), worse World Federation of Neurosurgical Societies classification and Fisher grade (odds ratio = 1.97, confidence interval = 1.64-2.36 and odds ratio = 1.89, confidence interval = 1.23-2.92, respectively), and increasing age (odds ratio = 1.07, confidence interval = 1.04-1.10) independently increased the risk of poor neurologic outcome at 3 months. Transfusion frequencies of RBCs, FFP, and platelets were relatively low. Intraoperative RBCT was strongly related to intraoperative rupture of the aneurysm in patients with poor-grade SAH. The observed association between poor outcome and RBCT in patients with SAH warrants further study.

A Reverse-Action Clip Applier for Aneurysm Surgery

Clipping is an important technique for cerebral aneurysm surgery. Although clip mechanisms and features have been refined, little attention has been paid to clip appliers. Clip closure is traditionally achieved by opening the grip of the clip applier. We reconsidered this motion and identified an important drawback, namely that the standard applier holding power decreased at the moment of clip release, which could lead to unstable clip application. To develop a forceps to address this clip applier design flaw. The new clip applier has a non--cross-type fulcrum that is closed at the time of clip release, with an action similar to that of a bipolar forceps or scissors. Thus, a surgeon can steadily apply the clip from various angles. We successfully used our clip applier to treat 103 aneurysms. Although training was required to ensure smooth applier use, no difficulties associated with applier use were noted. This clip applier can improve clipping surgery safety because it offers additional stability during clip release.

The neuroprotective effects of (S)-3,5-dihydroxyphenylglycine preconditioning in middle cerebral artery occluded rats: a perspective as a contrivance for stroke.

The neuroprotective effects of (S)-3,5-dihydroxyphenylglycine preconditioning in middle cerebral artery occluded rats: a perspective as a contrivance for stroke.

Risk Perception, Bias, and the Role of the Patient-Doctor Relationship in Decision Making about Cerebral Aneurysm Surgery

Treatment decisions in high-risk situations require a dynamic relationship between doctor and patient in which patient preferences and clinician recommendations contribute equally in shaping a final treatment decision.

Risk perception, bias, and the role of the patient-doctor relationship in decision making about cerebral aneurysm surgery.

Cognitive biases may negatively affect both patients' and physicians' decision making, especially when the stakes are high and the risks uncertain, so honesty in the patient-physician relationship and recognition of biases is critical.

The use of barbiturate-induced coma during cerebrovascular neurosurgery procedures: A review of the literature

Barbiturates are indicated for use during vascular neurosurgery procedures such as carotid surgery, arteriovenous malformation (AVM) surgery, cerebral aneurysm surgery, extracranial-intracranial bypass, and following significant bleeding due to AVMs or subarachnoid hemorrhage (SAH). These drugs are commonly used for their neuroprotective effects during focal cerebral ischemia and for their ability to treat intractable intracranial hypertension. Currently, thiopental and pentobarbital are the most frequently used barbiturates for these purposes, although methohexital and phenobarbital have been studied as well. Depending on the drug used and the desired effect, the dose administered may vary. Additionally, barbiturates are known to cause significant, severe side effects including depression of cardiac output, increased liver enzymes, increased risk of cardiac arrhythmia, lowered immune threshold, adversely affected brain temperature, systemic hypotension, and dyskalemia. For these reasons, these drugs should be monitored carefully and only used in circumstances of clear benefit. Finally, in order to evaluate barbiturates use during these procedures, information was gathered via an extensive PubMed literature review in addition to reviewing the resources of previous reviews on this topic or similar, relevant topics.

Testing of potential biomarkers of cerebral ischemia and vasospasm in patients with cerebral aneurysm surgery

Biomarkers for the prediction of vasospasm and delayed cerebral ischemia in patients with a ruptured cerebral aneurysm could be helpful.In this prospective clinical study, endothelin-1, lactate, pCO2, and pO2 were measured in arterial and internal jugular vein blood before, during and after surgical treatment of a cerebral aneurysm, and were tested as potential predictors of neurologic outcome in patients.Forty-one patients were enrolled in the study, 23 of them were operated on after aneurismal rupture with development of subarachnoid hemorrhage (SAH) and 18 patients were operated on for a nonruptured aneurysm.All of the involved patients survived. There was no difference in neurologic outcome between those operated on with a ruptured or nonruptured aneurysm.Endothelin-1 and lactate concentrations as well as pO2 and pCO2 from arterial and venous blood samples and their venoarterial difference did not differ between groups with and without an aneurismal rupture. Venoarterial difference of endothelin-1 concentrations on the day after surgery significantly differed between the groups with favorable and nonfavorable neurologic outcome. Other variables did not show a statistically significant difference.Significant correlation was found between endothelin-1 and lactate concentrations, suggesting involvement of the same pathophysiological process.Another interesting finding was lower arterial and venous pCO2 in patients with lower initial Glasgow Coma Scale (GCS) score and higher Hunt Hess score in the phase after extubation.We can conclude that the measured biochemical parameters did not show sufficient predictive power to be useful for prediction of cerebral vasospasm and neurologic outcome in everyday clinical practice. However, some correlations that do exist between them suggest involvement of the same pathophysiological process.

Intraoperative Arachnoid Plasty Has Possibility to Prevent Chronic Subdural Hematoma after Surgery for Unruptured Cerebral Aneurysms.

Some patients develop chronic subdural hematomas (CSDHs) after the clipping/coating of unruptured aneurysms. The risk factors are not well understood and while no preventive methods are currently available, arachnoid plasty (ARP) may intercept the development of postoperative CSDH. We investigated the risk factors for CSDH and the usefulness of ARP to prevent postoperative CSDH. Between January 2009 and June 2013, 393 patients underwent 416 aneurysm surgeries via the pterional approach at Kushiro Kojinkai Memorial Hospital. Of these, 394 aneurysms (371 patients) were included in this study. Using multivariate analysis we evaluated the relationship between the patient demographics and clinical characteristics, and the development of postoperative symptomatic CSDH. We also studied the effect of ARP performed during aneurysm surgery. We found that symptomatic CSDH developed after 20 (5.1%) of the 394 operations; it was addressed by burr hole surgery and evacuation/irrigation. Male gender, advanced age, and oral anticoagulant therapy were significant risk factors for CSDH. Additive ARP, performed in the course of 132 surgeries (33.5%) was found to be a significant negative risk factor. The incidence of CSDH was significantly lower in patients who had undergone ARP than in patients who had not undergone it (0.8% vs. 7.3%, p < 0.01). We first report that ARP is useful for the prevention of CSDH in patients treated by aneurysm surgery.

脳動脈瘤に対する直達手術

脳動脈瘤に対する直達手術

安全確実なclip操作を意識した未破裂脳動脈瘤手術

安全確実なclip操作を意識した未破裂脳動脈瘤手術

Motor-Evoked Potentials in Cerebral Aneurysm Surgery

Motor-Evoked Potentials in Cerebral Aneurysm Surgery

Indocyanine Green Angiography for Cerebral Aneurysm Surgery: Advantages, Limitations, and Neurosurgeon Intuition

Indocyanine Green Angiography for Cerebral Aneurysm Surgery: Advantages, Limitations, and Neurosurgeon Intuition

S40: Intraoperative neurophysiological monitoring in pediatric neurosurgery: a focus on the sacral system

s of Speakers / Clinical Neurophysiology 125, Supplement 1 (2014) S1–S339 S9 anodal direct cortical stimulation, activates the corticospinal tract close to the axon hillock at the border between the grey and the white matter. DCS remains the most focal stimulation possible and thus is favorable used for tumor removal within the vicinity of the motor cortex. MEPs became focus of neurooncological strategies for optimized glioma resection. Combining DCS-MEPs and monopolar cortical/subcortical stimulation mapping techniques in supratentorial tumor surgery as well as combination with intraoperative imaging could achieve supramarginal resection. The proposed subcortical stimulation motor threshold of 2 mA for safe resection has to be confirmed with regard to tumor type and precise location of stimulation. As been shown in cerebral aneurysm surgery, the ability to detect pure motor hemiparesis in carotid endarterectomy was more recently shown in a multicenter study. In spine surgery, presence or disappearance (“all-or-nothing” principle) of MEP amplitude criteria is commonly accepted: the presence of any MEPs is related to unaffected motor function or transient paresis, with the exception of radiculopathy. In cervical and thoracic intramedullary spinal cord surgery, the additional implementation of the D-wave helps to distinguish between permanent and transient motor deficit: D-wave preservation is always followed by a recovery of motor function. The latter seems to be applicable in supratentorial surgeries alike. In summary, MEPs are specific and sensitive for the assessment of the motor cortex and the corticospinal tract. In supratentorial tumor surgery MEPs are increasingly becoming a tool for “functional” guided resection strategies. S40 Intraoperative neurophysiological monitoring in pediatric neurosurgery: a focus on the sacral system F. Sala1, G. Squintani2, V. Tramontano2, C. Arcaro1 1Institute of Neurosurgery, Verona, Italy; 2Division of Neurology, Neurosciences, Verona, Italy Introduction: Intraoperative neurophysiologic monitoring (IOM) is nowadays extensively used in Pediatric Neurosurgery and tethered cord surgery is one of the most useful application. Our goal is to describe and discuss the standard IOM techniques used during tethered cord surgery, in the light of our clinical experience over the past ten years. Material and methods: Neurophysiological mapping of the conus-cauda is performed through direct stimulation of these structures and bilateral recording from segmental target muscles. While mapping identify ambiguous neural structures, their functional integrity during surgery can be assessed by monitoring techniques only, such as somatosensory evoked potentials (SEPs), transcranial motor evoked potentials (MEPs) from limb muscles and anal sphincters, and the bulbocavernosus reflex (BCR). Results: Between 2002 and 2012, we performed 48 surgical procedures in 47 patients with a tethered cord secondary to a variety of spinal dysraphisms. The monitorability rate was 84% for SEPs, 97% for limb muscle MEPs, 74% for the anal sphincter MEPs, and 59% for the BCR. In all patients but one SEP, MEP and BCR remained stable during surgery. Post-operatively two out of 47 patients presented a significant – though transient – neurological worsening. In six patients an unexpected muscle response was evoked by stimulating tissue macroscopically considered as not functional. Conclusions: Mapping techniques allow to identify and spare functional neural tissue and, vice-versa, to cut non-functional structures that may contribute to cord tethering. Monitoring techniques, MEP and BCR in particular, improve the reliability of intraoperative neurophysiology. IOM minimizes neurological morbidity in tethered cord surgery. S41 Neurophysiology of congenital mirror movements

Safety, efficacy, and cost of intraoperative indocyanine green angiography compared to intraoperative catheter angiography in cerebral aneurysm surgery

Intraoperative angiography in cerebrovascular neurosurgery can drive the repositioning or addition of aneurysm clips. Our institution has switched from a strategy of intraoperative digital subtraction angiography (DSA) universally, to a strategy of indocyanine green (ICG) videoangiography with DSA on an as-needed basis. We retrospectively evaluated whether the rates of perioperative stroke, unexpected postoperative aneurysm residual, or parent vessel stenosis differed in 100 patients from each era (2002, “DSA era”; 2007, “ICG era”). The clip repositioning rate for neck residual or parent vessel stenosis did not differ significantly between the two eras. There were no differences in the rate of perioperative stroke or rate of false-negative studies. The per-patient cost of intraoperative imaging within the DSA era was significantly higher than in the ICG era. The replacement of routine intraoperative DSA with ICG videoangiography and selective intraoperative DSA in cerebrovascular aneurysm surgery is safe and effective.

Evaluación del Tratamiento Quirúrgico de los Aneurismas Cerebrales. Hospital G. Almenara, 1983-1996

OBJETIVOS: Evaluar los factores que intervienieron en la evolución final de los pacientes operados de aneurismas cerebrales en el Hospital Guillermo Almenara Irigoyen-Lima, entre enero de 1983 y octubre de 1996. MATERIALES Y MÉTODOS: Se estudió 369 pacientes, evaluando las variables que pudieron haber influido en su evolución, como edad, grado de hemorragia subaracnoidea, localización del aneurisma, presencia de otros aneurismas o malformaciones asociadas, y complicaciones médicas y quirúrgicas. RESULTADOS: El 57,7% de los pacientes fueron mujeres. La edad promedio fue 46,6 ± 14,57. Según el grado de severidad de la hemorragia subaracnoidea, los grados II y III de Hunt y Hess fueron los más frecuentes (37 y 34%, respectivamente). Los aneurismas únicos fueron los más frecuentes (85%). La localización más frecuente fue sifón carotídeo (28,67%). La evolución al alta fue muy buena en el 42,5% y buena en el 32,5%. A mayor grado de severidad según Hunt y Hess, mayor morbimortalidad. Entre quienes presentaron neumonía como complicación, el 50% fallecieron. CONCLUSIONES: La evolución posoperatoria de estos pacientes es similar a la reportada en la literatura mundial. La neumonía se constituyó en una complicación importante.

23. Are persistent changes in SEPs and MEPs sensitive for predicting postoperative limb motor deficit during cerebral aneurysm surgery?

Introduction Motor evoked potentials (MEPs) can be used as an adjunct to somatosensory evoked potentials (SEPs) to identify brain ischemia during surgical treatment of cerebral aneurysms. Persistent changes (failure to return to baseline by end of surgery) can be used to predict postoperative deficit. The sensitivity, specificity, positive and negative predictive value of persistent changes in SEPs/MEPs for predicting neurologic deficit is still being defined. In a separate study, the sensitivity of persistent changes in SEPs for predicting new limb paresis was 13%, and MEPs was 32%. In this study we evaluated those patients with new postoperative motor deficits to determine the reason for the low sensitivity. Material and methods This was a retrospective study based on 446 cerebral aneurysm patients who underwent clipping at our institution from 2009–2011. Twenty-eight patients with new postoperative motor deficits were identified. The neuromonitoring reports and medical records were reviewed in more detail in these patients. Results In the 28 patients, ten patients (36%, sensitivity) were predicted by persistent SEPs/MEPs changes. In the 18 patients whose deficits were not predicted, five patients (18%) had delayed deficits; eight (29%) had mild temporary motor deficits; in two patients (7%), monitoring was stopped less than ten minutes after aneurysms were clipped; in one patient (3.6%), no reliable SEPs were recorded on the surgery side at baseline. If the last three cases are eliminated, the sensitivity of predicting for all deficit at time when patient wake up is 50% (10/20 patients); to severe and persistent motor deficit is 83% (10/12 patients). Conclusion This study demonstrates that the reason for the low sensitivity of SEPs/MEPs is that these methods are not sensitive to delayed and/or mild temporary deficits. However, the study also shows that SEPs/MEPs have better predictability in cases of severe and persistent postoperative limb paresis.

Augmented Reality in the Surgery of Cerebral Aneurysms

Augmented reality is the overlay of computer-generated images on real-world structures. It has previously been used for image guidance during surgical procedures, but it has never been used in the surgery of cerebral aneurysms. To report our experience of cerebral aneurysm surgery aided by augmented reality. Twenty-eight patients with 39 unruptured aneurysms were operated on in a prospective manner with augmented reality. Preoperative 3-dimensional image data sets (angio-magnetic resonance imaging, angio-computed tomography, and 3-dimensional digital subtraction angiography) were used to create virtual segmentations of patients' vessels, aneurysms, aneurysm necks, skulls, and heads. These images were injected intraoperatively into the eyepiece of the operating microscope. An example case of an unruptured posterior communicating artery aneurysm clipping is illustrated in a video. The described operating procedure allowed continuous monitoring of the accuracy of patient registration with neuronavigation data and assisted in the performance of tailored surgical approaches and optimal clipping with minimized exposition. Augmented reality may add to the performance of a minimally invasive approach, although further studies need to be performed to evaluate whether certain groups of aneurysms are more likely to benefit from it. Further technological development is required to improve its user friendliness.

Essentials in intraoperative indocyanine green videoangiography assessment for intracranial aneurysm surgery: conclusions from 295 consecutively clipped aneurysms and review of the literature

Indocyanine green (ICG) videoangiography (VA) in cerebral aneurysm surgery allows confirmation of blood flow in parent, branching, and perforating vessels as well as assessment of remnant aneurysm parts after clip application. A retrospective analysis and review of the literature were conducted to determine the current essential advantages of ICG-VA in aneurysm surgery. The authors retrospectively evaluated all aneurysm cases treated with the aid of intraoperative ICG-VA at a single institution between 2007 and 2013. They also analyzed the literature published since the initial description of ICG-VA in 2003. Two hundred forty-six procedures were performed in 232 patients harboring 295 aneurysms. The patients, whose mean age was 54 years, consisted of 159 women and 73 men. One hundred twenty-four surgeries were performed after subarachnoid hemorrhage, and 122 were performed for incidental aneurysms. Single aneurysms were clipped in 185 patients, and multiple aneurysms were clipped in 47 (mean aneurysm diameter 6.9 mm, range 2-40 mm). No complications associated with ICG-VA occurred. Intraoperative microvascular Doppler ultrasonography was performed before ICG-VA in all patients, and postoperative digital subtraction angiography (DSA) studies were available in 121 patients (52.2%) for retrospective comparative analysis. In 22 (9%) of 246 procedures, the clip position was modified intraoperatively as a consequence of ICG-VA. Stenosis of the parent vessels (16 procedures) or occlusion of the perforators (6 procedures), not detected by micro-Doppler ultrasonography, were the most common problems demonstrated on ICG-VA. In another 11 procedures (4.5%), residual perfusion of the aneurysm was observed and one or more additional clips were applied. Vessel stenosis or a compromised perforating artery occurred independent of aneurysm location and was about equally common in middle cerebral artery and anterior communicating artery aneurysms. In 2 procedures (0.8%), aneurysm puncture revealed residual blood flow within the lesion, which had not been detected by the ICG-VA. In the postoperative DSA studies, unexpected small (< 2 mm) aneurysm neck remnants, which had not been detected on intraoperative ICG-VA, were found in 11 (9.1%) of 121 patients. However, these remnants remained without consequence except in 1 patient with a 6-mm residual aneurysm dome, which was subsequently embolized with coils. In a large cohort of consecutive patients, ICG-VA proved to be a helpful intraoperative tool and led to a significant intraoperative clip modification rate of 15%. However, small, < 2-mm-wide neck remnants and a 6-mm residual aneurysm were missed by intraoperative ICG-VA in up to 10% of patients. Results in this study confirm that DSA is indispensable for postoperative quality assessment in complex aneurysm surgery.

工夫を要した穿通枝温存の症例から学ぶ

The preservation of perforating arteries is important to gain a favorable outcome in surgery for cerebral aneurysms. At our hospital, factors relating to difficulties in preservation of these vessels are analyzed in a video. There are several technical solutions to related surgical problems. 1) proximal clipping or aneurysm trapping 2) dome clipping to decrease aneurysm volume 3) special dissection technique in case of tight adhesion between perforator and aneurysm 4) neck clipping technique without detachment of perforator adhesion 5) dome cutting for obtaining better perforator blood flow These solutions can lead to a good outcome in cerebral aneurysm surgery by producing a better preservation rate of the perforator.