Tag: Clip

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The risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms

Acta Neurochirurgica (2023) 165:501–515

An anterior communicating artery is a common location for both ruptured and unruptured intracranial aneurysms, and microsurgery is sometimes necessary for their successful treatment. However, postoperative infarction should be considered during clipping due to the complex surrounding structures of anterior communicating artery aneurysms. This study aimed to evaluate the risk factors of postoperative infarction after surgical clipping of unruptured anterior communicating artery aneurysms and its clinical outcomes.

Methods The data of patients who underwent microsurgical clipping of an unruptured anterior communicating artery aneurysm in our hospital between January 2008 and December 2020 were retrospectively analyzed. The patients’ demographic data, anatomical features of the anterior communicating artery complex and aneurysm, surgical technique, characteristics of postoperative infarction, and its clinical course were evaluated.

Results Notably, among 848 patients, 66 (7.8%) and 34 (4%) patients had radiologic and symptomatic infarctions, respectively. Univariate and multivariate logistic regression analyses showed that hypertension (odds ratio (OR), 1.99; p = 0.022), previous stroke (OR, 3.89; p = 0.009), posterior projection (OR, 5.58; p < 0.001), aneurysm size (OR, 1.17; optimal cut-off value, 6.14 mm; p = 0.002), and skull base-to-aneurysm distance (OR, 1.15; optimal cut-off value, 11.09 mm; p < 0.001) were associated with postoperative infarction. In the pterional approach, a closed A2 plane was an additional risk factor (OR, 1.88; p = 0.041). Infarction of the subcallosal and hypothalamic branches was significantly associated with symptomatic infarction ( p = 0.001).

Conclusion Hypertension, previous stroke, posteriorly projecting aneurysms, aneurysm size, and highly positioned aneurysms are independent risk factors for postoperative infarction during surgical clipping of an unruptured anterior communicating artery aneurysm. Additionally, a closed A2 plane is an additional risk factor of postoperative infarction in patients undergoing clipping via the pterional approach.

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Microsurgical treatment of unruptured middle cerebral artery aneurysms

J Neurosurg 130:1498–1504, 2019

Advances in endovascular therapy for the treatment of middle cerebral artery (MCA) aneurysms have led to scrutiny of its benefits compared with microsurgical repair. To provide information regarding complication rates and outcomes, the authors reviewed the results of a large series of unruptured MCA aneurysms treated with open microsurgery.

METHODS The authors included all patients who underwent surgical repair of an unruptured MCA aneurysm between 1997 and 2015. All surgical procedures, including clipping, wrapping, bypass, and parent artery occlusion, were performed by a single neurosurgeon. Aneurysm occlusion was assessed using intraoperative digital subtraction angiography (DSA) or DSA and indocyanine green videoangiography in all cases. Postoperatively, all patients were monitored in a neurointensive care unit overnight. Clinical follow-up was scheduled for 2–4 weeks after surgery, and angiographic follow-up was performed in those patients with subtotally occluded aneurysms at 1, 2, and 5 years postoperation.

RESULTS The authors treated 750 unruptured MCA aneurysms in 716 patients: 649 (86.5%) aneurysms were small, 75 (10.0%) were large, and 26 (3.5%) were giant. Most aneurysms (n = 677, 90%) were treated by primary clip reconstruction. The surgical morbidity rate was 2.8%, and the mortality rate was 0%. Complete angiographic aneurysm occlusion was achieved in 92.0% of aneurysms. At final follow-up, 713 patients had a modified Rankin Scale (mRS) score of 0, 2 patients had an mRS score of 2 or 3, and 1 had an mRS score of 4.

CONCLUSIONS In high-volume centers, microsurgical management of MCA aneurysms can be performed with very low morbidity rates. Currently, microsurgical repair appears to be a highly effective method of treating MCA aneurysms.

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Clipping aneurysms improves outcomes for patients undergoing coiling

J Neurosurg 130:1491–1497, 2019

Most intracranial aneurysms are now treated by endovascular rather than by microsurgical procedures. There is evidence to demonstrate superior outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) treated by endovascular techniques. However, some cases continue to require microsurgery. The authors have examined the relationship between the number of aneurysms treated by microsurgery and outcome for patients undergoing treatment for aSAH at neurosurgical centers in England.

METHODS The Neurosurgical National Audit Programme (NNAP) database was used to identify aSAH cases and to provide associated 30-day mortality rates for each of the 24 neurosurgical centers in England. Data were compared for association by regression analysis using the Pearson product-moment correlation coefficient and any associations were tested for statistical significance using the one-way ANOVA test. The NNAP data were validated utilizing a second, independent registry: the British Neurovascular Group’s (BNVG) National Subarachnoid Haemorrhage Database.

RESULTS Increasing numbers of microsurgical cases in a center are associated with lower 30-day mortality rates for all patients treated for aSAH, irrespective of treatment modality (Pearson r = 0.42, p = 0.04), and for patients treated for aSAH by endovascular procedures (Pearson r = 0.42, p = 0.04). The correlations are stronger if all (elective and acute) microsurgical cases are compared with outcome. The BNVG data validated the NNAP data set for patients with aSAH.

CONCLUSIONS There is a statistically significant association between local microsurgical activity and center outcomes for patients with aSAH, even for patients treated endovascularly. The authors postulate that the number of microsurgical cases performed may be a surrogate indicator of closer neurosurgical involvement in the overall management of neurovascular patients and of optimal case selection.

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Analysis of superiorly projecting anterior communicating artery aneurysms

Analysis of superiorly projecting anterior communicating artery aneurysms

Neurosurg Rev (2016) 39:225–235

Superiorly projecting (SP) anterior communicating artery (AComA) aneurysms are typically described as a homogenous group. Clinically and microsurgically, these aneurysms vary in multiple important characteristics.

We propose a microsurgical classification system for these complex aneurysms and review its implications regarding presentation, microsurgical techniques, and outcome.

This retrospective analysis reviews patients undergoing clipping of SP AComA aneurysms (2005–2013). The classification system is based on the virtual plane created by the A2 segments and its relationship to the aneurysm. Aneurysm type was assessed by intraoperative images and videos. Type 1 is defined by bisection of the dome by the virtual plane. Type 2 is defined by dome projection posterior to this plane. Sagittal rotation of the plane defines type 3. We analyzed clinical presentation, morphology, angiographic characteristics, operative technique, and outcome relative to the classification types.

There were 44 SP AComA aneurysms. 3D angiographic images predicted classification type in 83 %. Type 1 presented more often with SAH (95.5 %, p=0.0046). There was no statistically significant difference between the types regarding patient demographics or aneurysm characteristics. In type 2, fenestrated clips were used frequently (87.5 % p=0.0016), and there was higher rate of intraoperative rupture (37.5 %). Although there was no statistically significant difference between the types in respect to HH grade upon presentation, patients with type 2 aneurysms experienced higher rates of poor GOS (50 %).

The proposed classification system for SP AComA aneurysms has implications regarding surgical planning, micro-dissection, clipping, and outcome. Type 2 aneurysms carry significant surgical risk.

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Aneurysm treatment in Europe 2010: an internet survey

Acta Neurochir (2012) 154:971–978. DOI 10.1007/s00701-012-1340-2

Aneurysm (AN) treatment appears to differ from country to country and even from centre to centre. Therefore we decided to conduct a survey in order to better understand the “state of the art” in aneurysm treatment in Europe. The primary aim was to understand the roles of clipping and coiling in aneurysm treatment.

Methods An interactive form was sent to major European neurosurgical centres. The responses relating to AN location, status (ruptured/unruptured) and treatment modality were divided with regard to the volume of cases and the centre’s geographical location.

Results Responses were received from 96 European centres. The main finding was that clipping was used significantly more often in Eastern Europe than in the rest of Europe to treat ruptured ANs of the anterior circulation. Almost all ruptured ANs across all locations are treated actively. The treatment of unruptured aneurysms of the anterior circulation is similar. The median relating to observed unruptured ANs across the Europe was 10 %. Posterior circulation ANs are treated predominantly by coiling, regardless of aneurysm status or geographical location. The average number of coilers versus surgeons per centre was 2.5:3.0 in Western, 1.9:3.6 in Southern, 1.9:4.3 in Eastern and 2.7:3.1 in Northern Europe.

Conclusions The way in which intracranial aneurysms are treated appears to correlate with the economic development of European countries. It is probably also affected by the lack of experienced coilers in Eastern Europe.

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A Novel Aneurysm Clip Design for Atheromatous, Thrombotic, or Previously Coiled Lesions

Neurosurgery 67[ONS Suppl 2]:ons333–ons341, 2010 DOI: 10.1227/NEU.0b013e3181f7451b

Large and giant lesions often have thicker, atheromatous walls as well as intra-aneurysmal thrombus that combine to prevent traditional clips from closing properly in some cases.

OBJECTIVE: To report the development and use of a novel clip design specifically tailored to treat atheromatous, thrombotic, or previously coiled aneurysms.

METHODS: We retrospectively reviewed the records of 6 patients with complex aneurysms not amenable to simple neck clipping and not considered appropriate for endovascular therapy who were treated using a novel ‘‘compression’’ clip design. We describe the development and use of a novel aneurysm clip design with blades that are not opposed at rest to allow direct clipping of atheromatous, thrombotic, and previously coiled aneurysms.

RESULTS: Four patients had recurrent, previously coiled aneurysms; one of these also had a large thrombotic component. Two patients had complex lesions with heavy atheroma involving a portion of their aneurysms. There were no complications related to the use of the clip, and all patients did well without neurological complications. In every case, the clip allowed straightforward obliteration of the aneurysm without the need for temporary vascular occlusion, aneurysmorrhaphy, or removal of an intra-aneurysmal coil mass. All patients underwent intraoperative angiography to confirm obliteration of the aneurysm with preservation of the normal vasculature.

CONCLUSION: Atheromatous, thrombotic, and previously coiled aneurysms may not be treatable with simple neck clipping and may not be curable with endovascular therapy. For such cases, we designed a novel ‘‘compression’’ clip that has been used safely and successfully in our experience with good short-term follow-up.

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