Titanium Aneurysm Clips Research Articles

INTRACRANIAL ARTERIAL LOOP WITH A COMPLEX PARTIALLY THROMBOSED LARGE ANEURYSM ON THE POSTERIOR CIRCULATION: WHAT TO DO NEXT?

Introduction Managing intracranial aneurysms in the posterior circulation is particularly challenging due to anatomical complexities and the high risk of rupture. The presence of a large, partially thrombosed aneurysm adds another layer of difficulty. This report details the case of a 66-year-old female patient presenting with a symptomatic intracranial arterial loop and a large, partially thrombosed aneurysm in the posterior circulation, successfully treated through microsurgical clipping. Material and Methods A 66-year-old female with a history of intermittent headaches, vertigo, and diplopia underwent neuroimaging, including computed tomography angiography (CTA) and magnetic resonance imaging (MRI). Imaging revealed a large aneurysm in the posterior circulation, with partial thrombosis and an associated intracranial arterial loop. The patient was scheduled for a craniotomy to perform microsurgical clipping of the aneurysm. Two titanium aneurysm clips were applied to achieve complete occlusion. Results Intraoperative findings confirmed the large, partially thrombosed aneurysm arising from the basilar artery, with a complex arterial loop intricately intertwined with the aneurysm and adjacent neurovascular structures. The first clip was placed to secure the primary inflow, and the second clip provided additional reinforcement. Postoperative imaging demonstrated successful clipping with no residual aneurysm filling. The patient had an uneventful recovery with no immediate postoperative complications. Clinically, the patient reported significant improvement in symptoms, with a complete resolution of headaches and vertigo. Conclusions This case highlights the challenges and considerations in managing large, partially thrombosed aneurysms in the posterior circulation, particularly in the presence of an intracranial arterial loop. Successful management requires precise microsurgical technique and careful intraoperative decision-making. Further research is needed to optimize treatment strategies, potentially incorporating adjunctive endovascular techniques to enhance surgical outcomes.

Neuroapraxia of Trigeminal Nerve Controlled by Neuromonitoring During Microvascular Decompression in Multiple Sclerosis Patients Affected by Drug-Resistant Trigeminal Neuralgia Recurrent After Previous Operations

BACKGROUND AND IMPORTANCE: Trigeminal neuralgia (TN) can complicate the clinical course of multiple sclerosis (MS) and can be very difficult to treat. Usually, these patients experience multiple recurrences after surgical procedures with a poor overall outcome. To the best of our knowledge, we report the first 3 cases of drug-resistant MS-related TN recurrent after previous operations in which intraoperative neuromonitoring controlled neuroapraxia of trigeminal nerve was performed. We describe the surgical technique, report the clinical outcomes of patients, and review the pertinent literature. CLINICAL PRESENTATION: Neuroapraxia of trigeminal nerve was conducted using a standard straight Yasargil temporary titanium aneurysm clip on the main trunk of the trigeminal nerve. Trigeminal somatosensory evoked potentials and cortico-bulbar motor evoked potentials registered from trigeminal and facial nerves were recorded during the procedure. The trigeminal nerve clipping was conducted for a maximum of 30 seconds or less in the case of a decrease in neurophysiological responses. The preoperative Barrow Neurological Institute score was V, IV, and IV for the 3 patients, respectively. We obtained acute pain relief in all patients after the procedure. All patients had a Barrow Neurological Institute I at the latest follow-up (10, 10, and 9 months, respectively). No complications were reported postoperatively and at follow-up. CONCLUSION: Intraoperative neuromonitoring controlled neuroapraxia of trigeminal nerve with temporary titanium aneurysm clip application during microvascular decompression is a promising and safe procedure in MS patients with recurrent MS-related TN. Further studies with longer follow-up are needed to confirm our encouraging results.

Neurapraxia in patients with trigeminal neuralgia but no identifiable neurovascular conflict during microvascular decompression: a retrospective analysis of 26 cases

BackgroundMicrovascular decompression (MVD) is the first choice in patients with classic trigeminal neuralgia (TGN) that could not be sufficiently controlled by pharmacological treatment. However, neurovascular conflict (NVC) could not be identified during MVD in all patients. To describe the efficacy and safety of treatment with aneurysm clips in these situations.Methods A total of 205 patients underwent MVD for classic TGN at our center from January 1, 2015 to December 31, 2019. In patients without identifiable NVC upon dissection of the entire trigeminal nerve root, neurapraxia was performed using a Yasargil temporary titanium aneurysm clip (force: 90 g) for 40 s (or a total of 60 s if the process must be suspended temporarily due to bradycardia or hypertension).ResultsA total of 26 patients (median age: 64 years; 15 women) underwent neurapraxia. Five out of the 26 patients received prior MVD but relapsed. Immediate complete pain relief was achieved in all 26 cases. Within a median follow-up of 3 years (range: 1.0–6.0), recurrence was noted in 3 cases (11.5%). Postoperative complications included hemifacial numbness, herpes labialis, masseter weakness; most were transient and dissipated within 3–6 months.ConclusionsNeurapraxia using aneurysm clip is safe and effective in patients with classic TGN but no identifiable NVC during MVD. Whether this method could be developed into a standardizable method needs further investigation.

Intraoperative Shortening of Aneurysm Clips: Revisiting an Old Technique in a New Era

It can sometimes be challenging to find a suitable clip to treat an unusual aneurysm, or when the surrounding anatomy is unusual, especially in resource-limited environments. We describe a method to modify aneurysm clips based on the method originated by Sugita etal in 1985. Herein clip modification (Clip-Mod) is used to treat anatomically difficult anterior communicating artery aneurysms. The Department of Neurological Surgery database was reviewed to find aneurysm patients treated using modified aneurysm clips. Clip-Mod was performed during surgery by shortening the tines of titanium aneurysm clips by abrasion applied from the side of a standard 3-mm surgical diamond drill bit under constant irrigation. Note that the thickness of the tines and the clip spring were not modified or contacted by the drill. Four cases used modified aneurysm clips, from 648 total clip-treated aneurysms (0.6%) by 2 surgeons over a 14-year period. Three patients presented with subarachnoid hemorrhages that were determined to be due to anterior communicating artery aneurysms. One patient presented with an incidental unruptured anterior communicating artery aneurysm. All 4 patients were treated with 3-mm titanium clips shortened intraoperatively to 1- to 2-mm lengths, to achieve aneurysm obliteration without stenosing parent or perforating vessels. All 4 patients have done well clinically with no reoccurrences after 2-6 years' follow-up, which included angiographic evaluation. The use of this "Clip-Mod" technique thus appears useful for anterior communicating artery aneurysms. Clip-Mod could also be considered for treating other aneurysms when the "perfect" length clip is not available.

Poly-Arginine Peptide-18 (R18) Reduces Brain Injury and Improves Functional Outcomes in a Nonhuman Primate Stroke Model.

Poly-arginine peptide-18 (R18) is neuroprotective in different rodent middle cerebral artery occlusion (MCAO) stroke models. In this study, we examined whether R18 treatment could reduce ischemic brain injury and improve functional outcome in a nonhuman primate (NHP) stroke model. A stroke was induced in male cynomolgus macaques by MCAO distal to the orbitofrontal branch of the MCA through a right pterional craniotomy, using a 5-mm titanium aneurysm clip for 90min. R18 (1000nmol/kg) or saline vehicle was administered intravenously 60min after the onset of MCAO. Magnetic resonance imaging (MRI; perfusion-weighted imaging, diffusion-weighted imaging, or T2-weighted imaging) of the brain was performed 15min, 24h, and 28days post-MCAO, and neurological outcome was assessed using the NHP stroke scale (NHPSS). Experimental endpoint was 28days post-MCAO, treatments were randomized, and all procedures were performed blinded to treatment status. R18 treatment reduced infarct lesion volume by up to 65.2% and 69.7% at 24h and 28days poststroke, respectively. Based on NHPSS scores, R18-treated animals displayed reduced functional deficits. This study confirms the effectiveness of R18 in reducing the severity of ischemic brain injury and improving functional outcomes after stroke in a NHP model, and provides further support for its clinical development as a stroke neuroprotective therapeutic.

Mechanical Evaluation of Long Titanium Alloy Clip: Comparison of Cobalt Alloy Clip

Long titanium aneurysm clips have recently been released. In the present study, comparative study of long titanium and cobalt alloy clips was performed. Two kinds of Sugita long clips (straight clips of 25- and 35-mm blade length) made of titanium and cobalt alloys were tested by measuring the closing force, the anti-scissoring torque, and the maximum opening width. There were some differences between the two materials. In the 25-mm blade length clip, closing force and maximum opening width of titanium alloy clip were greater than those of cobalt alloy clip. By contrast, the anti-scissoring torque of 35-mm blade length titanium clip was stronger than that of the cobalt. The long titanium clips would have equivalent endurance to long cobalt clip and are safe for clinical use.

Artifact quantification and tractography from 3T MRI after placement of aneurysm clips in subarachnoid hemorrhage patients

BackgroundThe application of advanced 3T MRI imaging techniques to study recovery after subarachnoid hemorrhage (SAH) is complicated by the presence of image artifacts produced by implanted aneurysm clips. To characterize the effect of these artifacts on image quality, we sought to: 1) quantify extent of image artifact in SAH patients with implanted aneurysm clips across a range of MR sequences typically used in studies of volumetry, blood oxygen level dependent signal change (BOLD-fMRI), and diffusion-weighted imaging (DW-MRI) and 2) to explore the ability to reconstruct white matter pathways in these patients.MethodsT1- and T2-weighted structural, BOLD-fMRI, and DW-MRI scans were acquired at 3T in two patients with titanium alloy clips in ACOM and left ACA respectively. Intensity-based planimetric contouring was performed on aligned image volumes to define each artifact. Artifact volumes were quantified by artifact/clip length and artifact/brain volume ratios and analyzed by two-way (scan-by-rater) ANOVAs. Tractography pathways were reconstructed from DW-MRI at varying distances from the artifacts using deterministic methods.ResultsArtifact volume varied by MR sequence for length (p = 0.007) and volume (p < 0.001) ratios: it was smallest for structural images, larger for DW-MRI acquisitions, and largest on fMRI images. Inter-rater reliability was high (r = 0.9626, p < 0.0001), and reconstruction of white matter connectivity characteristics increased with distance from the artifact border. In both patients, reconstructed white matter pathways of the uncinate fasciculus and inferior fronto-occipital fasciculus were clearly visible within 2 mm of the artifact border.ConclusionsAdvanced 3T MR can successfully image brain tissue around implanted titanium aneurysm clips at different spatial ranges depending on sequence type. White matter pathways near clip artifacts can be reconstructed and visualized. These findings provide a reference for designing functional and structural neuroimaging studies of recovery in aSAH patients after clip placement.

The New Aneurysm Clip System for Particularly Complex Aneurysm Surgery

Currently, there is an ongoing debate regarding the best treatment option for ruptured aneurysms. The International Subarachnoid Aneurysm Trial study suggests that an endovascular procedure is the best treatment. In some complex cases, or in patients with an additional large intracerebral hemorrhage, aneurysms require further microsurgical clipping. We introduce a new clip system to improve clipping procedures in especially complex aneurysms. The inverted opening mechanism of the clip in combination with the special clip applier provides the surgeon with a good overview in the operating field. The new design also enables a wider opening of the clip jaws in contrast to all other well-known titanium aneurysm clips. This should provide a better and safer application and decrease the danger of premature rupture. From January 2006 to July 2008, 55 aneurysms were clipped in 45 patients. The most common aneurysm location was the anterior communicating artery (20 patients) followed by the M1 segment of the middle cerebral artery (16 patients). Four patients had 2, one had 3, and one had 5 aneurysms. Two clipping procedures were performed for an arteriovenous malformation-associated aneurysm. All aneurysms were clipped without any technical complication. The use of the new clip system, especially in complex aneurysm surgery, has potential benefits because of the better surgical vision during clip application and the wider opening of the clip jaws. It is easy to handle and compatible with magnetic resonance imaging.

Mechanical characteristics and surface elemental composition of a Yasargil titanium aneurysm clip after long-term implantation

The mechanical properties of titanium-alloy aneurysm clips after long-term implantation in the human cranium are unclear. The characteristics of a Yasargil titanium aneurysm clip were evaluated after long-term implantation for 12 years in a patient with a cerebral aneurysm. The closing forces of the retrieved clip before and after implantation were approximately equal. The bending test showed no differences between the retrieved and control clips. Titanium oxide and calcium were identified on the surface of the retrieved clip, which indicated the formation of corrosion-resistant layers. Titanium-alloy clips retain their mechanical properties in the human cranium for a long time.

ACUTE CONFUSIONAL SYNDROME FROM A DURAL ARTERIOVENOUS FISTULA

We describe a case of an acute confusional state associated with a right parietal dural arteriovenous fistula. A 67-year-old man in his usual state of health experienced an acute confusion episode preceded by a valsalva maneuver. The episode lasted approximately 60 minutes. Afterward he was able to remember everything that occurred. A magnetic resonance imaging scan suggested a right parietal dural arteriovenous fistula, which was confirmed by angiography. A seizure was ruled out by clinical examination and an electroencephalogram. The patient underwent therapeutic embolization and surgical ligation of the fistula. Feeding vessels to the malformation were cauterized within the leaves of the falx, and the draining vein was clipped with a titanium aneurysm clip and divided. An intraoperative angiogram was then performed, which showed obliteration of the fistula. There was no demonstrable confusion or memory loss noted postoperatively. We propose that venous hypertension from the dural arteriovenous fistula in combination with a valsalva maneuver caused ischemia in the right parietal lobe, eliciting a deficit in attention.

Optimizing computed tomography to reduce artifacts from titanium aneurysm clips: an in vitro study

Object At many institutions digital subtraction angiography remains the standard imaging procedure for the postoperative evaluation of patients following placement of a cerebral aneurysm clip largely because of the artifacts produced by the clip on computed tomography (CT). The authors evaluated the effect of various imaging parameters on the quality of 3D reconstructions from CT scans while imaging a phantom to optimize the CT angiograms. Methods Using multidetector CT scanners with submillimeter detector collimation (0.625 mm), the authors scanned a silicone phantom with attached commercial aneurysm clips. Slice thickness, reconstruction overlap, kilovolt level, milliampere level, and pitch were varied. Neuroradiologists, who were blinded to the scanning parameters, rated the reconstructions for image quality and artifact reduction. Results Images of the titanium clip using 140 kV and 380 mA with 0.625-mm overlapping reconstructed slices provided excellent 3D visualization of both the clip and the aneurysm model, even when using two adjacent clips. Conclusions Overlapping reconstructions combined with thin-section acquisition can provide detailed images of titanium clips and surrounding tissues without the use of low-pitch values.

Optimizing computed tomography to reduce artifacts from titanium aneurysm clips: an in vitro study

At many institutions digital subtraction angiography remains the standard imaging procedure for the postoperative evaluation of patients following placement of a cerebral aneurysm clip largely because of the artifacts produced by the clip on computed tomography (CT). The authors evaluated the effect of various imaging parameters on the quality of 3D reconstructions from CT scans while imaging a phantom to optimize the CT angiograms. Using multidetector CT scanners with submillimeter detector collimation (0.625 mm), the authors scanned a silicone phantom with attached commercial aneurysm clips. Slice thickness, reconstruction overlap, kilovolt level, milliampere level, and pitch were varied. Neuroradiologists, who were blinded to the scanning parameters, rated the reconstructions for image quality and artifact reduction. Images of the titanium clip using 140 kV and 380 mA with 0.625-mm overlapping reconstructed slices provided excellent 3D visualization of both the clip and the aneurysm model, even when using two adjacent clips. Overlapping reconstructions combined with thin-section acquisition can provide detailed images of titanium clips and surrounding tissues without the use of low-pitch values.

The New Aneurysm Clip System for Complex Aneurysm Surgery

The new L-Aneurysm-Clip-System has been developed due to the current indication for clipping of complex aneurysms (such as fusiform, broad-based, small < 4.0 mm, large or giant, and partially thrombosed, and aneurysms associated with intracerebral hemorrhages) This system has many advantages in comparison to the Yasargil-Clip and the Pernetzky- Clip. The inverted opening mechanism of the clips enables the surgeon to have a total overview of the clips and of the clip applier in the operating field. This system prevents the clip from being covered by the applying forceps. The new design concept allows a bigger opening of the L-clips jaws, more than all other well-known titanium aneurysm clips have, thus offering a better and safer application and decreasing premature rupture danger.

Endurance of aneurysm clips: mechanical endurance of Yaşargil and Spetzler titanium aneurysm clips.

To determine whether repeated use weakens titanium aneurysm clips, making them unsafe for clinical use. Nine Yaşargil (titanium alloy) and five Spetzler (pure titanium) clips were subjected to clinically relevant maneuvers, and the effects on the closing force were assessed. Clips were considered unsafe if 1) the blades crossed, 2) the clips failed to close completely, or 3) the blood pressure could open them. Yaşargil and Spetzler clips significantly (P < 0.01 for both) weakened, by 18.9% and 26.1%, respectively, after 10 minutes of sustained maximal opening. After 100 open-close cycles, Spetzler clips showed no change in closing force, but the closing force of Yaşargil clips decreased significantly (P < 0.01), by a further 12.0%. Repeated use weakens Spetzler and Yaşargil clips. All Spetzler and all but one Yaşargil clips were deemed safe for clinical use at the end of the experiments.

Risk of intraoperative aneurysm clip slippage: a new experience with titanium clips

Slippage of an aneurysm clip as a result of insufficient clip-closing force cannot be predicted, even when using force-testing devices. Descriptions of intraoperative clip slippages are rarely found in the literature. The authors summarize four unusual cases in which titanium aneurysm clips slipped by a scissorslike mechanism during surgery. They analyze the possible factors implicated in such a dangerous situation and discuss corrective choices.

MR imaging in patients with intraspinal bullets

MR imaging in patients with intraspinal bullets

Clipes de titânio no tratamento de aneurismas saculares intracranianos

ResumoEste trabalho descreve a utilização de 25 clipes de titânio no tratamento de 20 pacientes com hemorragia subaracnóide aneurismática. Todos os pacientes apresentavam hemorragias de graus I e II na escala de Hunt e Hess, provocadas por aneurismas da circulação anterior. O resultado do tratamento cirúrgico foi bom, não ocorrendo qualquer complicação, precoce ou tardia, que pudesse ser atribuída aos clipes de titânio. As dimensões médias dos artefatos provocados pelos clipes na tomografia computadorizada (TC) (comprimento) e ressonância magnética (RM) (volume) foram de 17,65 mm e 1,64 cm3 , respectivamente. Os clipes de titânio demonstraram ser cirurgicamente seguros e efetivos e, quando comparados com os clipes de liga de cobalto disponíveis no comércio, produziram artefatos bem menores nas imagens obtidas pela TC e RM, devido a sua menor susceptibilidade magnética. Com base nessas importantes vantagens, acreditamos que os clipes de titânio devam ser considerados como a opção ideal para uso rotineiro em cirurgias de aneurismas.

Spiral CT angiography in demonstration of cerebral aneurysms before and after treatment with titanium clips

To determine the suitability of spiral CT angiography (SCTA) in patients with intracerebral titanium aneurysm clips. The section parameters were optimised using a phantom. 16 patients were examined preoperatively and 18 following treatment of aneurysms with clips. The resolution, sensitivity and specificity for demonstrating cerebral aneurysms measuring > or = 3 mm was 91.3% and 75% respectively. In 15 patients with intracerebral clips there were no or only minor artefacts; three examinations were of no value because of major metal artefacts. Amongst six aneurysms demonstrated angiographically, two, which measured more than 3 mm, could be shown by SCTA. SCTA was able to demonstrate intracerebral aneurysms measuring > or = 3 mm. Titanium clips did not usually affect image quality significantly.

Titanium Aneurysm Clips: Part III Clinical Application in 16 Patients with Subarachnoid Hemorrhage

This report describes the first clinical use of newly developed titanium clips in the treatment of 16 patients with subarachnoid hemorrhage. There were no immediate or delayed complications related to the titanium clips. Thirteen patients had good outcomes, and one patient had moderate disabilities (mean follow-up, 5.4 mo). Two patients with Hunt and Hess Grade IV hemorrhages died postoperatively. The average cross-sectional areas of clip artifact on postoperative magnetic resonance imaging studies was 0.96, 1.36, and 1.05 cm2 on T1-, T2-, and intermediate-weighted images, respectively. In comparison, a matched control group with cobalt alloy clips had average cross-sectional areas of 3.13, 3.70, and 2.81 cm2 on T1-, T2-, and intermediate-weighted images, respectively. The average artifact volumes on gradient echo magnetic resonance images for titanium and cobalt alloy clips were 1.8 and 10.1 cm3, respectively. In addition, the gap on magnetic resonance imaging angiograms from clip artifacts was 0.9 cm with titanium and 2.6 cm with cobalt alloy clips. In conclusion, titanium aneurysm clips seem to be safe and effective and seem to reduce clip artifacts on magnetic resonance imaging threefold, compared with commercially available cobalt alloy clips. Because of this important advantage over conventional clips, titanium clips should be considered for routine use in aneurysm surgery.

Titanium Aneurysm Clips: Part III-Clinical Application in 16 Patients with Subarachnoid Hemorrhage

THIS REPORT DESCRIBES the first clinical use of newly developed titanium clips in the treatment of 16 patients with subarachnoid hemorrhage. There were no immediate or delayed complications related to the titanium clips. Thirteen patients had good outcomes, and one patient had moderate disabilities (mean follow-up, 5.4 mo). Two patients with Hunt and Hess Grade IV hemorrhages died postoperatively. The average cross-sectional areas of clip artifact on postoperative magnetic resonance imaging studies was 0.96, 1.36, and 1.05 cm2 on T1-, T2-, and intermediate-weighted images, respectively. In comparison, a matched control group with cobalt alloy clips had average cross-sectional areas of 3.13, 3.70, and 2.81 cm2 on T1-, T2-, and intermediate-weighted images, respectively. The average artifact volumes on gradient echo magnetic resonance images for titanium and cobalt alloy clips were 1.8 and 10.1 cm3, respectively. In addition, the gap on magnetic resonance imaging angiograms from clip artifacts was 0.9 cm with titanium and 2.6 cm with cobalt alloy clips. In conclusion, titanium aneurysm clips seem to be safe and effective and seem to reduce clip artifacts on magnetic resonance imaging threefold, compared with commercially available cobalt alloy clips. Because of this important advantage over conventional clips, titanium clips should be considered for routine use in aneurysm surgery.