Temporary Clip Application Research Articles

Under recognized yet a clinically relevant impact of aneurysm location in Distal Anterior Cerebral Artery (DACA) aneurysms: insights from a contemporary surgical experience.

Aneurysms of the distal anterior cerebral artery (DACA) are rare but surgically challenging. Despite a known therapeutic implication of the aneurysm location on the DACA territory, the literature is unclear about its clinical and prognostic significance. Our surgical experience over the last 5 years was reviewed to compare the clinical, operative, and outcome characteristics between aneurysms located below the mid portion of the genu of the corpus callosum (called proximal aneurysms) to those distal to this point (called distal aneurysms). A prognostic factor analysis was done using uni and multivariable analysis. A total of 34 patients were treated (M: F = 1:2.3). The distal group had a higher frequency of poor clinical grade at presentation (n = 9, 47.4%) in contrast to (n = 2, 13.3%) proximal aneurysms (p = 0.039). Despite an overall tendency for a delayed functional improvement in these patients, the results were mainly due to favorable outcomes in the proximal group (favourable functional outcomes at discharge and at last follow-up being 80% and 86.7% respectively). On the multivariable analysis, only WFNS grade (> 2) at presentation (OR = 13.75; 95CI = 1.2-157.7) (p = 0.035) and application of temporary clips (AOR = 34.32; 95CI = 2.59-454.1) (p = 0.007), both of which were more in the distal group, independently predicted a poor long term functional outcome. Thus, the aneurysm location impacts the preoperative clinical grade, the intraoperative aneurysm rupture risk rate as well as the temporary clipping requirement. A combination of these factors leads to worse short and long-term functional outcomes in the distal DACA aneurysms.

AI-powered real-time annotations during urologic surgery: The future of training and quality metrics

Introduction and objectiveReal-time artificial intelligence (AI) annotation of the surgical field has the potential to automatically extract information from surgical videos, helping to create a robust surgical atlas. This content can be used for surgical education and qualitative initiatives. We demonstrate the first use of AI in urologic robotic surgery to capture live surgical video and annotate key surgical steps and safety milestones in real-time. Summary background dataWhile AI models possess the capability to generate automated annotations based on a collection of video images, the real-time implementation of such technology in urological robotic surgery to aid surgeon and training staff it is still pending to be studied. MethodsWe conducted an educational symposium, which broadcasted 2 live procedures, a robotic-assisted radical prostatectomy (RARP) and a robotic-assisted partial nephrectomy (RAPN). A surgical AI platform system (Theator, Palo Alto, CA) generated real-time annotations and identified operative safety milestones. This was achieved through trained algorithms, conventional video recognition, and novel Video Transfer Network technology which captures clips in full context, enabling automatic recognition and surgical mapping in real-time. ResultsReal-time AI annotations for procedure #1, RARP, are found in Table 1. The safety milestone annotations included the apical safety maneuver and deliberate views of structures such as the external iliac vessels and the obturator nerve. Real-time AI annotations for procedure #2, RAPN, are found in Table 1. Safety milestones included deliberate views of structures such as the gonadal vessels and the ureter. AI annotated surgical events included intraoperative ultrasound, temporary clip application and removal, hemostatic powder application, and notable hemorrhage. ConclusionsFor the first time, surgical intelligence successfully showcased real-time AI annotations of 2 separate urologic robotic procedures during a live telecast. These annotations may provide the technological framework for send automatic notifications to clinical or operational stakeholders. This technology is a first step in real-time intraoperative decision support, leveraging big data to improve the quality of surgical care, potentially improve surgical outcomes, and support training and education.

Letter: Commentary: The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms.

Letter: Commentary: The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms.

Can the Processed EEG Be Utilized as a Cerebral Ischemia Monitor during the Temporary Clip Application in Anterior Circulation Aneurysm Surgery?

AbstractPatients undergoing cerebral aneurysm clipping are at risk for cerebral ischemia. Ischemic tolerance varies among individuals. Hence, multimodal intraoperative neuromonitoring (IONM) is essential. IONM is not available in many centers. This case report highlights the utilization of processed electroencephalography (EEG) as a cerebral ischemia monitor during temporary clip application. Our patient underwent clipping of a ruptured anterior-communicating artery aneurysm. After the temporary clip applications on the right and left, A1 arterial segments led to a transient drop of somatosensory evoked potentials (SSEPs). At the same time, the frontal four-channel processed EEG showed a burst suppression (BS) pattern. Blood pressure augmentation and the removal of temporary clips helped restore the SSEP back to baseline and the disappearance of the BS pattern in processed EEG. During the steady state of anesthesia, the sudden appearance of the BS pattern in processed EEG can be attributed to clip-induced cerebral ischemia after ruling out other potential causes for BS.

Intra-operative cerebral blood flow assessment by indocyanine green video-angiography after temporary arterial occlusion in aneurysm surgery and its clinical implications: a prospective study.

Objective Indocyanine green video angiography (ICG-VA) is a routine while performing vascular surgery to assess patency of perforators, completeness of clipping and/or to assess patency of anastomosis. Its usefulness in assessing cerebral blood flow and perfusion is not well studied. This study is aimed to assess the cerebral blood flow and perfusion after temporary clipping and to correlate with the risk of ischemia.Methods Prospective analysis of intra-operative ICG-VA performed during temporary arterial occlusion in 38 patients from January 2014 to December 2018 was conducted. Co-relation with post-operative MR diffusion weighted imaging (MR DWI) in terms of vascular territory of interest within 48 hours of surgery was performed. Clinical outcome was assessed using modified Rankin Scale (mRS) score 1-month post-surgery.Results 43 aneurysms in 38 patients clipped using ICG-VA were included in this study. No side effect of ICG dye was seen in any patients. The number of times temporary clips applied had a direct relationship to the delay in appearance of ICG in the surgical field which became statistically significant after application of 3rd temporary clip. Nine (23.7%) patients developed ischemia following the procedure confirmed by post-operative MR DWI and all the ischemic cases had visible decrease in ICG fluorescence post-temporary clipping.Conclusions No previous study had tried to assess the intraoperative cerebral blood flow and perfusion during temporary clipping of parent vessels during aneurysm surgery. The use of ICG-VA can be extended to assess perfusion in desired territory by merely assessing the degree of opacification.

Optimal Use of Temporary Clip Application during Aneurysm Surgery - In Search of the Holy Grail.

Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were “Temporary Clip,” “Temporary Clipping,” “Cerebral Aneurysm,” and “Aneurysm.” Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.

Intraoperative Rerupture and Surgical Clipping of a Small Superiorly Projecting Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

Anterior communicating artery (ACoA) aneurysms are prone to rupture even at smaller sizes. The surgical management of ACoA aneurysms is highly dependent on the spatial orientation of the saccular projection, categorized as inferior, superior, anterior, or posterior. Superior projecting aneurysms constitute approximately one-third of all aneurysms involving the ACoA. These aneurysms commonly project within the interhemispheric fissure; however, if the aneurysm is not high-riding, it can often be approached via a transsylvian trajectory. The patient presented after subarachnoid hemorrhage with a 3-mm superiorly projecting ACoA aneurysm. The lesion was approached via a right modified orbitozygomatic craniotomy with a transsylvian trajectory. The aneurysm reruptured after minimal manipulation of the dome. Mitigation of the intraoperative rupture was achieved through temporary clip application to bilateral A1 vessels. Bipolar coagulation and placement of 2 permanent clips facilitated final aneurysm occlusion. Postoperative imaging demonstrated patent bilateral A2 flow and no residual aneurysm filling. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Microsurgical clipping of distal basilar trunk aneurysm during adenosine-induced profound hypotension

A 46-year-old male presented with a history of sudden severe headache 1 week back, altered sensorium and right hemiparesis for 2 days. On examination, Glasgow Coma Scale (GCS) was E4V4M6 and the patient had right hemiparesis (power – 4/5). Computed tomography (CT) revealed diffuse subarachnoid hemorrhage (Fisher's Grade III). CT angiogram revealed distal basilar trunk aneurysm arising between the origin of the left posterior cerebral artery and superior cerebellar artery, ectatic dilatation of distal basilar trunk, and a left middle cerebral artery (MCA) bifurcation aneurysm. Basilar trunk aneurysm was approached through subtemporal route and aneurysm was clipped during adenosine-induced profound hypotension (AIPH) without application of temporary clip. Single bolus 6 mg of adenosine was given, and aneurysm was successfully clipped during AIPH (systolic <60 mmHg). There were no complications related to adenosine. Ectatic part of distal basilar trunk was wrapped with Teflon. The left MCA bifurcation aneurysm was clipped in the same session. At 3-month follow-up, the patient's sensorium was normal (GCS-E4V5M6) and the right hemiparesis improved (4+/5). Adenosine enhances the safety of clipping these aneurysms by providing transient cardiac arrest or profound hypotension. In developing countries, microsurgical clipping is a cost-effective treatment option for basilar artery aneurysms.

Factors determining the best surgical exposure and safe clip positioning in surgical treatment of anterior communicating artery (AComA) aneurysms - particular significance of AComA complex rotation in the axial plane.

The aim of this study was to evaluate whether Anterior Communicating Artery (AComA) complex rotation in axial plane may influence the ease of surgical exploration in this region and safety of clip positioning when left vs right-sided approach is compared. This is a retrospective study based on analysis of patients operated due to AComA aneurysm, both ruptured and unruptured. AComA complex position in relation to coronal plane was evaluated using 3D-CTA VR reconstructions. Next, comparison between surgical approach from the side where A1-A2 junction (angle) was located anterior and posterior to coronal plane was performed in relation to surgical difficulties and intra- and postoperative complications. Subgroup statistical analysis revealed that there is a strong and statistically significant correlation between AComA complex rotation and surgical difficulties expressed by the need of repeated temporary clip application and brain transgression. When anterior vs posterior angle side approach was compared in relation to surgical difficulties and complications, there was a statistically significant difference with strong correlation (p &lt; 0.05) in favour of posterior angle side approach. Interestingly, in 72.7% and 45.5% of patients that were operated from the side where A1-A2 junction was located posterior to coronal plane, the approach was performed form the side of a non-dominant A1 and aneurysm dome projection side, respectively. Despite its limitations, our results suggest that microsurgical clipping strategy of AComA aneurysms should at least include AComA complex rotation in axial plane, besides well acknowledged factors, when deciding from which side these lesions will be approached.

Double-balloon trapping for coil embolization of ruptured internal carotid artery aneurysm: A novel technique

Introduction:Endovascular treatment of complex ruptured aneurysms in the internal carotid (IC) artery is extremely challenging. Navigation of double-balloon catheters becomes all the more difficult in tortuous vessels.Patients and Methods:A 57-year-old female with more than three times previously ruptured left IC artery aneurysm with subarachnoid hemorrhage had a left IC small aneurysm with a neck of 3.2 mm. Proximal and distal balloons were inflated in left IC artery in respect to the aneurysm, to prevent further rupture during navigation of the microcatheter and first coil.Discussion:The technique uses two balloons placed proximal and distal to the ruptured aneurysm, to reduce further bleeding, just as the application of temporary clips, followed by inertion of coils rapidly to obliterate the aneurysm.Conclusion:It is a novel technique of double-balloon trapping of proximal and distal segment of IC artery with aneurysm coiling technique as an alternative to balloon-assisted coiling and stent-assisted coiling in patients with ruptured aneurysm.

Cerebral infarction caused by accidental incarceration of aneurysm-adjacent branches with temporary clips

Objective To explore the potential reasons of cerebral infarction caused by accidental incarceration of aneurysm-adjacent branches with temporary clips, and to give guidance to the appropriate application of temporary clips. Methods A retrospective analysis was conducted on the clinical data of 10 patients with accidental incarceration of branches of parent artery or aneurysm-adjacent perforator vessels who were admitted to Department of Neurosurgery of Fuzhou General Hospital from January 2004 to December 2016. Under microscopes, we observed the definite lesions of branches and perforator vessels during the procedures, features of temporary clips and the intraoperative procedure, and postoperative cerebral infarction with varying degrees in corresponding territories. Two cases of posterior communicating artery aneurysm and 2 cases of carotid bifurcation aneurysm were found on the extracranial superior mesenteric artery adventitia with varying degrees of atherosclerosis, misclipping occurred at the anterior pre-choroidal artery, recurrent artery of Heubner and lenticulostraiate artery. For 4 cases of anterior communicating artery aneurysms and 2 cases of middle cerebral artery aneurysm, mis-clipping was found at A1 or A2 and M1 segments adjacent to perforation. Results Among the 10 patients, CT review 2-4 days post surgery demonstrated cerebral infarction with varying degrees adjacent to the aneurysm branches, perforating branch of blood supply. Disturbance of consciousness occurred in 2 cases. Compared with preoperative state, short-term significant decrease in strength of limb muscles was observed in 5 cases, incomplete motor aphasia in 1 and asymptomatic cerebral infarction in 2. At follow-up ranging from 4 months to 3 years, 2 cases reported dementia and 2 cases had permanent hemiplegia, out of which 3 were disabling and needed long-term care. Conclusions Cerebral infarction caused by accidental incarceration of branches or perforator vessels with temporary clips could be related not only to the incarceration duration, age and vascular sclerosis, but also to the over-contraction of small blood vessels and the closing force of a temporary clip. Therefore, caution should be warranted regarding those factors in the use of temporary clips. Key words: Intracranial aneurysm; Vascular system injuries; Therapeutic occlusion; Brain infarction

Quantitative study of the opticocarotid and carotid-oculomotor windows for the interpeduncular fossa, before and after internal carotid artery mobilization and posterior communicating division.

The management of basilar apex (BX) aneurysms remains problematic. We quantified the surgical exposure of the BX through the opticocarotid window (OCW) and the carotid-oculomotor window (COW), before and after mobilization of the internal carotid artery and division of the posterior communicating artery (PCoA). Eleven silicone-injected cadaveric heads were dissected bilaterally. The surgical dissection was divided into 4 major steps: (1) supraorbital modified orbitozygomatic craniotomy, (2) mobilization of the internal carotid artery after drilling out the anterior clinoid process intradurally and cutting the distal dural ring, (3) drilling out the posterior clinoid process and dorsum sellae, and (4) dividing the PCoA from the posterior third portion of the vessel. A frameless navigation system was used to quantify the surgical exposure area of the BX through the OCW and COW. The total surgical area increased significantly from steps 1 to 4 (P < .001) in both OCW and COW groups. Overall, there was a larger total surgical area obtained in the COW compared with the OCW (P = .010). ICA mobilization increased the surgical area for temporary (P < .001) and permanent (P < .003) clip application in both windows. The division of PCoA significantly increased the overall surgical area for permanent clip application (P < .003). Compared with the OCW, the COW had a significantly increased change in the area for permanent clip application in the low-lying group (P = .03). When approaching the BX via the pterion route, the appropriate surgical step and window should be selected according to characteristics of the PCoA and height of the BX.

Double-clip technique for the microneurosurgical management of very small (< 3 mm) intracranial aneurysms.

The treatment of very small (≤ 3 mm) aneurysms is technically challenging. Mini-clips used for clipping these small aneurysms have a smaller closing force compared with standard clips. To describe the double-clip technique for very small aneurysms. The double-clip technique, a parallel duplication clipping technique of booster clipping, is used by the senior author for clipping very small aneurysms with morphology suitable for the application of 2 clips. The aneurysm is clipped after application of temporary clip(s), administration of adenosine, or both. An initial mini-clip is applied, leaving a small residual neck sufficient for application of the second mini-clip. A second mini-clip of the same size and shape is applied on the residual neck parallel to the initial clip. The initially applied mini-clip, which is in close contact with the second clip, supports the second clip and prevents its slippage. This technique was retrospectively reviewed over a 13-year period (1997-2009). There were 3246 patients with 4757 aneurysms treated in the same period. The outcomes of 39 patients with 40 very small aneurysms clipped with the double-clip technique were analyzed. None of the patients had technique-related complications. Postoperative angiograms revealed complete aneurysm occlusion of 39 aneurysms and a small residual neck in 1 aneurysm. No parent artery obstruction was observed in the postoperative angiogram. The double-clip technique is a safe and effective variation of booster clipping in the treatment of very small aneurysms with suitable morphology.

The Use of Adenosine in Cerebral Aneurysm Clipping: A Review

Management of intracranial aneurysms continues to evolve, with coiling of aneurysms becoming an increasingly used modality. However, for aneurysms which are considered to be “complex” due to their size, position, or morphology, clipping continues to be the preferred treatment option. Several techniques can be utilized intraoperatively to facilitate aneurysm exposure and clip ligation. These include deep hypothermic circulatory arrest, endovascular balloon occlusion with suction, and, most commonly, temporary clip application to the proximal feeding vessel. The use of these techniques has been limited by the associated significant morbidity and mortality, and in the case of temporary clipping, anatomic limitations preventing clip application in certain cases. Recently, adenosine induced transient circulatory arrest has undergone a resurgence in neurosurgical practice to assist in complex aneurysm clip ligation. In this article we review this technique with special emphasis on appropriate patient selection and safety profile.

初心者の脳動静脈奇形摘出術

Surgical resection of cerebral arteriovenous malformations (AVMs) is a certain but difficult treatment because of its complicated pathology and the sometimes limited experience of the neurosurgeon. Therefore, care in deciding the surgical indication and strategy is essential. We report three cases of AVMs from the viewpoint of an inexperienced neurosurgeon. Preoperative embolization was performed in all cases, while in one patient there was a hemorrhagic complication causing neurological deterioration. All AVMs were extirpated with established techniques and procedures. For a beginner in AVM surgery, the proper selection of cases was thought to be most important. As for the surgical technique, extensive opening of the sulci and fissures, proximal control by temporary clip application on feeders and blunt dissection of the nidus without coagulation were indispensable.

Intraoperative dynamic assessment of the posterior communicating artery and its branches by indocyanine green videoangiography

Background:True hemodynamic assessment of the posterior communicating artery (PComA) by preoperative angiography in terms of its perforators and configuration (adult vs. fetal vs. transitional) can be challenging in the surgical treatment of aneurysms involving the PComA, posterior cerebral artery, and basilar artery. Indocyanine green videoangiography (ICG-VA) is a widely accepted new technique in the surgical treatment of intracranial aneurysms to assess the patency of the parent artery, branches, and residual flow within the aneurysm after clipping.Case Description:Here we report two cases in which ICG-VA was utilized to assess either the direction of flow in the PComA or preservation of the PComA perforators with temporary clip application before dividing the PComA.Conclusions:Our experience is that ICG-VA can be used to assess the main trunk, and perforating branches of the PComA providing real-time, dynamic intraoperative information of the surgical field. Therefore we suggest that ICG-VA may increase the safety of surgical treatment of aneurysm involving PComA.

Regional variations in brain oxygenation during temporary clipping in aneurysm surgery

Objectives: Brain tissue oxygen concentration (PbtO2) monitoring has been used in aneurysm surgery to detect decreased brain oxygenation during temporary clipping. The effects of circulatory interruption according to different aneurysm locations have not been established. In this work, variations in PbtO2 during temporary clipping were studied in anterior communicating (AcomA), posterior communicating (PcomA) origin, and middle cerebral artery (MCA) aneurysm surgery.Methods: PbtO2 was monitored during surgery of 41 patients; aneurysms were located in the AcomA (10 cases), origin of PcomA (8 cases), and MCA bifurcation (23 cases). Temporary clips were used in all cases. Variations in PbtO2 values obtained during application of temporary clips were evaluated and studied according to the duration and type of circulatory interruption for each aneurysm location.Results: In AcomA aneurysm surgery, a significant decrease in PbtO2 values was found in 31% of the periods of temporary clipping, whereas in PcomA and MCA aneurysm surgery, significant decreases were found in all temporary clip applications (100%). In MCA aneurysms, the amplitude of decrease in PbtO2 was higher when the circulatory interruption lasted for 2 or more minutes, compared with shorter periods of temporary clipping.Discussion: During temporary clipping, different variations in PbtO2 values were obtained when comparing frontal and temporal regions of monitoring: in MCA and PcomA origin aneurysms, significant variations were registered in all periods of temporary regional circulatory interruption, but the same results were not found in frontal monitoring for AcomA aneurym surgery.

Intraoperative brain oxygenation monitoring and vasospasm in aneurysmal subarachnoid hemorrhage

Background: Vasospasm is a frequent complication of subarachnoid hemorrhage (SAH), implicated in poor outcome, and prediction of its occurrence might be important on the therapeutic approach of this condition. Brain oxygenation in aneurysmal SAH was prospectively monitored during surgery in 28 patients, using brain tissue oxygen pressure (PbtO2), studying its association with the occurrence of post-operative vasospasm, detected by transcranial Doppler.Methods: PbtO2 monitoring was performed during surgery of 28 patients with aneurysmal SAH, using a polarographic microcatheter (Licox; GMS, Kiel, Germany), inserted into the cerebral tissue. The aneurysms were localized in the anterior communicating artery (AcoA) complex (eight cases), in the posterior communicating artery (Pcom) origin (seven cases), and in the middle cerebral artery (MCA) bifurcation (13 cases). Basal PbtO2 values, obtained immediately before application of temporary or definitive clips, were studied according to age, clinical status and CT findings. The association between the basal values and the occurrence of increased blood flow velocity in the post-operative transcranial Doppler (TCD vasospasm) was investigated.Results: Post-operative TCD vasospasm developed in 13 patients, all of them with basal values inferior to 10 mmHg. PbtO2 basal value was significantly lower in cases that developed TCD vasospasm. This association was independent of age, clinical status, or CT findings.Conclusion: The finding of low intraoperative basal PbtO2 values may be an indicator for a high risk of occurrence of post-operative TCD vasospasm in cases of aneurysmatic SAH.

Can a Self-Expanding Aneurysm Stent Be Clipped? Emergency Proximal Control Options for the Vascular Neurosurgeon

If a self-expanding stent has been placed during endovascular treatment of an aneurysm and subsequently an open aneurysm surgery becomes necessary in the same or an adjacent area, is it possible and safe to obtain proximal control by placing a temporary clip on the artery at a point where it contains the stent? To evaluate the effect of temporary clip application to 3 separate stent systems in an in vitro flow model with the stated hypothesis that clip application to these stents will result in permanent stent deformation. This is an in vitro flow model study using an accepted synthetic blood vessel substitute. The Neuroform(3) (Boston Scientific), Enterprise (Cordis/Codman), and Pipeline (ev3) stents were deployed within the flow model; temporary clips were applied; and angiographic measurements subsequently made. Two 4 × 30-mm Neuroform(3) stents, two 4.5 × 28-mm Enterprise stents, and two 3.75 × 20-mm Pipeline stents were successfully deployed and clipped repeatedly (4 iterations). Two- and 3-dimensional angiograms were obtained. After repeated clip occlusion, the Neuroform(3) and Enterprise stents returned to their original configuration and diameter. Clip application to both also resulted in immediate flow arrest. In contrast, initial clip application to the Pipeline stents did not result in flow arrest, but the second single clip application did. The Pipeline stents were also irreversibly deformed after the experimental protocol, with an average luminal diameter reduction of 26.85% (P < .05). The Neuroform(3) and Enterprise stents responded favorably to temporary clip application, returning to their original diameter after clip removal and showing no sign of permanent structural modification. The Pipeline flow-diverting stent, however, was irreversibly deformed by clip application. These data indicate that temporary clip application to certain stents is possible. Further in vivo study is required.

A Wake “Anesthesia” for Intraoperative Language Testing During Temporary Clip Application in a Patient With Giant Intracranial Aneurysm

Bilotta, Federico MD, PhD*; Santoro, Antonio MD†; Rosa, Giovanni MD* Author Information