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Bar graph showing an increased incidence of symptomatic ischemic complication in patients undergoing temporary arterial occlusion lasting longer than 10 minutes. TAO : temporary arterial occlusion.
Source publication
This study was performed to elucidate the technical and patient-specific risk factors for postoperative ischemia in patients undergoing temporary arterial occlusion (TAO) during the surgical repair of their aneurysms.
Eighty-nine consecutive patients in whom TAO was performed during surgical repair of an aneurysm were retrospectively analyzed. The...
Context in source publication
Context 1
... : anterior communicating artery, ICA : internal carotid artery, MCA : middle cerebral artery, ACA : anterior cerebral artery ents undergoing temporary occlusion for less than 10 min- utes and 44% (23 cases) in those undergoing temporary occlusion for more than 10 minutes. There was no signi- ficant association between the outcome and the duration of temporary occlusion (p = 0.151). Univariate analysis reveal- ed that increased duration of temporary occlusion was associated with a significant increase in symptomatic ischemic complication (p = 0.010) (Fig. 3) and radiologic ischemic complication (p = ≤ ...
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Citations
... Although being a widespread technique, TAO is associated with perioperative stroke in ruptured aneurysm cases, which is more likely to occur in patients with older age, Hunt-and-Hess grade IV and V, early surgery, and single prolonged clip placement 12,13 . Ischemic complications secondary to TAO also depend on the location of clip placement, occlusion duration, and the use of neuroprotective strategies, such as intraoperative neurophysiological monitoring of somatosensory evoked potentials [14][15][16] and intraoperative hypothermia [17][18][19] . ...
Purpose
Temporary arterial occlusion (TAO) is a widespread practice in the surgical treatment of intracranial aneurysms. This study aimed to investigate TAO’s role during ruptured aneurysm clipping as an independent prognostic factor on short- and long-term outcomes.
Methods
This prospective cohort included 180 patients with ruptured intracranial aneurysms and an indication of microsurgical treatment. Patients who died in the first 12 hours after admission were excluded.
Results
TAO was associated with intraoperative rupture (IOR) (odds ratio – OR = 10.54; 95% confidence interval – 95%CI 4.72–23.55; p < 0.001) and surgical complications (OR = 2.14; 95%CI 1.11–4.07; p = 0.01). The group with TAO and IOR had no significant difference in clinical (p = 0.06) and surgical (p = 0.94) complications compared to the group that had TAO, but no IOR. Among the 111 patients followed six months after treatment, IOR, number of occlusions, and total time of occlusion were not associated with Glasgow Outcome Scale (GOS) in the follow-up (respectively, p = 0.18, p = 0.30, and p = 0.73). Among patients who underwent TAO, IOR was also not associated with GOS in the follow-up (p = 0.29).
Conclusions
TAO was associated with IOR and surgical complications, being the latter independent of IOR occurrence. In long-term analysis, neither TAO nor IOR were associated with poor clinical outcomes.
Key words
Intracranial Aneurysm; Subarachnoid Hemorrhage; Microsurgery; Intraoperative Complications; Treatment Outcome
... However, prolonged occlusion of arterial blood flow carries risks of regional ischemic sequelae and is frequently associated with unfavorable outcomes, yet there is no consensus on the safe time duration for temporary occlusion for protecting against relevant ischemic damage. [8][9][10] Recently, robotic assistance in surgeries has expanded to nearly all surgical subspecialties. This technical note details 3 cases that demonstrate an innovative application of robotic arms for safeguarding microsurgical clipping of pericallosal and middle cerebral artery (MCA) aneurysms. ...
... Given the delicacy of aneurysm clipping, extended and repeated occlusion may be required in some cases, and prolonged occlusions carry significant risks for ischemic injury. 9,14,15 Numerous risk factors also render the procedure of high IAR risks, including surgeon's experience and other unexpected complications (ie, atheroma, penetration of the aneurysm neck). The safeguard device enables the surgeon to perform additional manipulations on difficult aneurysms safely, with the confidence of knowingly having control over the arterial blood flow in the event of IAR. ...
BACKGROUND:
Managing intraoperative aneurysm rupture (IAR) during intracranial aneurysm clipping can be challenging given the excessive hemorrhage and limited field of view under the microscope for visualizing the proximal artery and safe temporary clipping.
OBJECTIVE:
To describe the first known use of robotic arm for safeguarding IAR in microsurgical aneurysm clipping.
METHODS:
A robotic arm was used to safeguard 3 microsurgical clipping cases (1 pericallosal and 2 middle cerebral artery) performed by a single surgeon. The device was installed onto the side rail of the operating table along with the clip applier attachment. After dissecting the cerebral artery segment proximal to the aneurysm, a temporary aneurysm clip was loaded and established at the appropriate segment before dissecting distally toward the aneurysm.
RESULTS:
Setup for the robotic arm and temporary clip was simple, quick, precise, and without any unforeseen accommodations needed in all 3 instances. The temporary clip acted as an emergency gate and could be deployed either manually or remotely through a controller. IAR occurred in case 1, and the robotic-assisted temporary clip deployment achieved immediate hemostasis without complications. This method bypassed the need for significant suctioning, packing, and further exploration for safe temporary clipping. Case 2 and 3 demonstrated the feasibility for middle cerebral artery protection and ease of intraoperative readjustment.
CONCLUSION:
This technical note highlights the feasibility and relative ease of using a robotic arm as a safeguard device, and it enables on-demand control of proximal blood flow and may enhance the safety of microsurgical aneurysm procedures.
... Increasing age is a risk factor for developing BRI. Prolonged artery occlusion is a known risk factor for postoperative ischemia, [4] but in our study, we found no association with BRI and the use of temporary artery occlusion. This is not surprising considering our definition of BRI: cortical hypodensities in the surgical trajectory not matching areas of large arterial infarction. ...
Background
BRI is estimated to occur in 10% of skull-base surgery and 5% of aneurysm surgery. These estimates are based on a few studies with unclear methodology. The purpose of this study is to assess the rate of BRI occurrence, its risk factors, and the association between BRI and postoperative focal neurological deficit in patients that underwent elective aneurysm surgery in a single institution.
Methods
All patients that underwent elective aneurysm surgery in a single tertiary center in the Netherlands were included. BRI was defined as cortical hypodensities in the surgical trajectory not matching areas of large arterial infarction. Risk ratios were calculated between BRI and (a) the use of temporary parent artery occlusion during clipping, (b) anterior communicating artery (ACom), and (c) middle cerebral artery (MCA) location of the aneurysm, (d) presence of mentioned CVA risk factors, (e) the clipping of > 1 aneurysm during the same procedure, and (f) new focal neurological deficit. Statistical analysis further included t-tests and binary logistical regression analysis on the correlation between age and BRI.
Results
BRI was identified postoperatively in 42 of the 94 patients included in this study. A new focal neurological deficit was found in 7 patients in the BRI group. A total of 5 patients had persisting symptoms at 3-month follow-up, of which 2 were caused by BRI. Increasing age is a risk factor for developing BRI.
Conclusions
The high rate of BRI and significant risk of new postoperative focal neurological deficit in our patients should be considered when counseling patients for elective aneurysm surgery.
... However, the benefits of delayed over early surgical intervention in regard to resistance to ischemia is counteracted by the risks of a wait and watch approach, especially when the overall management of patients with SAH ruptured aneurysms is considered which has also been confirmed by another study. 7) The duration of temporary occlusion remains the most investigated factor in clinical series of patients who undergo TAO. 11)13) In our study, we observed a trend for a decreased incidence of ischemic complication and good outcome in patients in whom temporary vessel occlusion was performed for less than 5 minutes. ...
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.
... Most experimental studies focused on EPO treatment within the first hours following vessel occlusion [7], simulating the unpredictable situation clinicians face in the emergency department or in the stroke unit after sudden onset of a neurological deficit. However, with the advent of interventions in the cardio-and cerebrovascular systemssuch as carotid endarterectomy and stenting, coronary artery bypass grafting, percutaneous coronary and cerebrovascular thrombectomy, angioplasty or coiling, and clipping of cerebral aneurysmsthat carry an increased risk of stroke or require transient cerebral artery occlusion [19][20][21][22][23][24][25][26], anticipatory neuroprotection preceding a risk-related procedure demands greater attention [27]. In this context, experiments on a rodent model for transient middle cerebral artery occlusion (MCAO) suggest that beneficial effects of EPO treatment before ischemia onset can have a definite (if indirect) impact on the extent of ischemic edema and preservation of BBB function [27]. ...
Objective
This study was designed to investigate the indirect neuroprotective properties of recombinant human erythropoietin (rhEPO) pretreatment in a rat model of transient middle cerebral artery occlusion (MCAO).
Methods
One hundred and ten male Wistar rats were randomly assigned to four groups receiving either 5,000 IU/kg rhEPO intravenously or saline 15 minutes prior to MCAO and bilateral craniectomy or sham craniectomy. Bilateral craniectomy aimed at elimination of the space-consuming effect of postischemic edema. Diagnostic workup included neurological examination, assessment of infarct size and cerebral edema by magnetic resonance imaging, wet–dry technique, and quantification of hemispheric and local cerebral blood flow (CBF) by flat-panel volumetric computed tomography.
Results
In the absence of craniectomy, EPO pretreatment led to a significant reduction in infarct volume (34.83 ± 9.84% vs. 25.28 ± 7.03%; p = 0.022) and midline shift (0.114 ± 0.023 cm vs. 0.083 ± 0.027 cm; p = 0.013). We observed a significant increase in regional CBF in cortical areas of the ischemic infarct (72.29 ± 24.00% vs. 105.53 ± 33.10%; p = 0.043) but not the whole hemispheres. Infarct size-independent parameters could not demonstrate a statistically significant reduction in cerebral edema with EPO treatment.
Conclusions
Single-dose pretreatment with rhEPO 5,000 IU/kg significantly reduces ischemic lesion volume and increases local CBF in penumbral areas of ischemia 24 h after transient MCAO in rats. Data suggest indirect neuroprotection from edema and the resultant pressure-reducing and blood flow-increasing effects mediated by EPO.
... It is suspected that temporary clipping might cause ischemic complications during aneurysm surgery [7,[10][11][12]. However, the literature is conflicting with regard to which factors related to temporary clipping are associated with ischemic complications. ...
... However, although the use of temporary clips more frequently resulted in ischemic complications, the difference was not significant. In contrast, another study reported a lower incidence of ischemia in patients with an increased number of temporary arterial occlusions than in patients with single temporary occlusion [10]. According to the study findings, repeated temporary arterial occlusion resulted in fewer ischemic complications by allowing intermittent reperfusion of the corresponding territory. ...
... The findings indicated that the rate of symptomatic stroke was 12 % and 35 % in patients who underwent temporary occlusion for ≤10 min and ≥10 min, respectively. Ha et al. also reported that patients with an increased duration of temporary occlusion exhibited a significantly higher incidence of symptomatic and radiological ischemia [10]. However, in most studies, analysis of the duration of a single temporary clipping and the total duration of temporary clipping was not conducted; therefore, the literature remains conflicting. ...
Objective
Temporary clipping of the internal carotid artery can be required during microsurgery of a ruptured anterior choroidal artery (AchoA) aneurysm. Although it is suspected that such temporary clipping might be related to ischemic complications following surgery, no detailed analysis has been reported yet.
Patients and methods
Eighty-nine patients with ruptured AchoA aneurysms treated by microsurgical clipping were recruited between January 1996 and December 2017. Patient medical records, radiographic data, and intraoperative video findings were retrospectively reviewed. Multivariate logistic regression analysis was conducted to investigate the risk factors for treatment-related ischemic complications.
Results
Treatment-related ischemic complications occurred in eight (9.0%) patients, all of whom underwent temporary clipping during microsurgery. Patients who did not undergo temporary clipping (n = 20) did not experience treatment-related ischemic complications. Among patients who underwent temporary clipping (n = 69), multivariate logistic regression analyses indicated that the total duration, number of attempts, and longest time per attempt were not risk factors for poor clinical outcome at discharge. However, the longest time
per attempt was identified as the only independent risk factor for treatment-related ischemic complications (odds ratio, 2.883; 95% confidence interval, 1.725-6.525; P = 0.042).
Conclusion
The longest time per attempt might be associated with a higher risk of treatment-related ischemic complications during microsurgery for ruptured AchoA aneurysms. Treatment-related ischemic complications may be minimized by intermittent application of temporary clipping during surgery.
... In addition, studies have sho�n that depressurization treatment should not be performed during surgery to reduce the occurrence of postoperative serious complications, such as cerebral infarction (15). Important traffic arteries should not be clipped during surgery to reduce the occurrence of permanent dysfunction (16). ...
The clinical efficacy of microsurgical neck clipping for the treatment of cerebral aneurysm rupture and its effect on serum nuclear factor κ‑light-chain-enhancer of activated β cells (NF-κB), monocyte chemoattractant protein-1 (MCP-1) and matrix metalloproteinase-9 (MMP-9) levels were investigated. A total of 56 patients with first occurrence of cerebral aneurysm rupture were enrolled from June 2015 to June 2016. These patients were divided into control (25 patients) and observation groups (31 patients) according to treatment received. The patients in the control group were treated with interventional embolization and extraventricular drainage, while the patients in the observation group were treated with microsurgical neck clipping. Serum NF-κB, MCP-1 and MMP-9levels were measured by ELISA prior to the operation and at 6 h post‑operation. Clinical effects were compared at the 6-month follow-up. There was no significant difference in the success rate of the operation between the two groups (p>0.05). The incidence of complications in the observation group was significantly lower than that in the control group (p<0.05). The GlasgowOutcome Scale score was significantly improved in the observation group (p<0.05) compared with the control group. Serum NF-κB, MMP-9and MCP-1 were significantly decreased in both groups at 6 and 24 h after operation, but the observational group showed significantly lower levels for all three proteins than the control group (p<0.05). The application of early microsurgical neck clipping for the treatment of cerebral aneurysm rupture can reduce complications and improve clinical prognosis, and this may be related to a decrease in serum inflammatory response‑related factors (NF-κB and MCP-1) and MMP-9.
... If TVO needs to be extended beyond that, as in complex or multiple aneurysms, intermittent reperfusion is recommended to avoid post-operative neurological damage. [118,119] S u z u k i e t a l . , a d v o c a t e d a c o m b i n a t i o n o f mannitol (500 ml of 20% solution), Vitamin E (500 mg) and dexamethasone (50 mg), referred to as the Sendai cocktail for TVO, particularly if it needs to be prolonged. ...
The anaesthetized brain is vulnerable to ischaemic insults, which could result in neurological deficits ranging from neuropsychological disturbances to stroke and even death. The risk of perioperative brain injury is relatively high in cardiac, neurosurgical and major vascular surgery, although it has also rarely been reported in noncardiac nonneurosurgical operations. Besides underlying risk factors such as cerebrovascular disease, advanced age, and cardiovascular disease, anaesthesia and surgery per se could also be a contributory factor. The anaesthesiologist plays a pivotal role in protecting the anaesthetized brain, both by taking preventive measures and instituting brain protection strategies. Despite advances and breakthroughs in pharmacological neuroprotection in the laboratory, currently there is no drug, anaesthetic or non-anaesthetic, which is available for clinical use. The anaesthesiologist has to rely on non-pharmacological modalities and neuromonitoring to prevent intraoperative brain injury
... Regional circulatory interruption by application of temporary clips on the parental artery is a current technique in aneurysm surgery, used for safer dissection of the aneurysm and for control of intraoperative aneurysm rupture. The main problem of temporary clipping is the occurrence of brain ischemia, with postoperative cerebral infarction, due to extended time of temporary arterial occlusion.[1579–11141517] The safe temporary occlusion time is not known, and great variations have been described.[67910131517] ...
... Mortality and morbidity directly related to surgical treatment of ruptured MCA aneurysms are usually associated with intraoperative aneurysm rupture and with ischemia due to prolonged regional circulatory interruption or inadequate placement of the definitive clip leading to vascular occlusion.[1571011141517] Temporary clips are often used to control intraoperative aneurysm rupture and to facilitate aneurysm dissection. ...
... The main problem of temporary clipping is the occurrence of brain ischemia, with postoperative cerebral infarction, due to extended time of temporary arterial occlusion.[1579–11141517] The safe temporary occlusion time is not known, and great variations have been described.[67910131517] Incorrect placement of the definitive clip with incidental total or partial arterial occlusion is another possible cause for ischemia. ...
The occurrence of brain ischemic lesions, due to temporary arterial occlusion or incorrect placement of the definitive clip, is a major complication of aneurysm surgery. Temporary clipping is a current technique during surgery and there is no reliable method of predicting the possibility of ischemia due to extended regional circulatory interruption. Even with careful inspection, misplacement of the definitive clip can be difficult to detect. Brain tissue oxygen concentration (PtiO(2)) was monitored during surgery of middle cerebral artery (MCA) aneurysm presenting with subarachnoid hemorrhage (SAH), for detection of changes in brain oxygenation due to reduced blood flow, as a predictor of ischemic events, during temporary clipping and after definitive clipping.
PtiO(2) was monitored during surgery of 13 patients harboring MCA aneurysms presenting with SAH, using a polarographic microcatheter (Licox, GMS, Kiel, Germany) placed in the territory of MCA.
A decrease in PtiO(2) values was verified in every period of temporary clipping. Brain infarction occurred in 2 patients; in both cases, there was a decrease in PtiO(2) greater than 80% from basal value, a minimum value of less than 2 mmHg persisting for 2 or more minutes during temporary clipping, and an incomplete recovery of PtiO(2) after definitive clipping. In 2 patients, incomplete recovery of values after definitive clipping led to verification of inappropriate placement and repositioning of the clip.
The results suggest that intraoperative monitoring of PtiO(2) may be a useful method of detection of changes in brain tissue oxygenation during MCA aneurysm surgery. Postoperative infarction in the territory of MCA developed in cases with an abrupt decrease of PtiO(2) and a very low and persistent minimum value, during temporary clipping, and an incomplete recovery after definitive clipping. Verification of clip position should be considered when there is an incomplete recovery or a persistent fall in PtiO(2) after definitive clipping.
... Surgery is currently used for treatment of incidental unruptured middle cerebral artery aneurysms.[11] Intra-operative aneurysm rupture and ischemia dependent on prolonged regional circulatory interruption or inadequate placement of the definitive clip leading to vascular occlusion and post-operative brain infarction are direct causes of mortality and morbidity related to surgery.[1571215181921] Temporary clips are used to deal with intra-operative aneurysm rupture and to facilitate aneurysm dissection, and a method of monitoring that could predict the danger for ischemia during temporary clip application and after the placement of definitive clip could be an important contribution for the safety of aneurysm surgery. ...
... Regional circulatory interruption by application of temporary clips is a current technique in aneurysm surgery, for safer dissection of the aneurysm and for control of intra-operative aneurysm rupture. However, ischemic events can occur with the possibility of post-operative cerebral infarction,[16–81012161921] even in cases of incidental aneurysm surgery, either due to temporary arterial clipping or to incorrect placement of the definitive clip.[1571215181921] We performed intra-operative monitoring of brain tissue oxygen concentration (PtiO2), to evaluate PtiO2 values in “normal brain” and to detect changes in brain oxygenation, due to reduced blood flow, that may be indicative of high risk for cerebral ischemia and post operative brain infarction during surgery of middle cerebral artery incidental aneurysms. ...
The management of incidental unruptured aneurysms remains a matter of controversy; middle-sized or large anterior circulation incidental aneurysms, in young or middle age patients, should be considered for treatment. Surgical clipping is an accepted treatment for middle cerebral artery unruptured aneurysms. Ischemic events can occur even in cases of incidental aneurysm surgery. Since regional cerebral blood flow can be compromised due to temporary arterial clipping or to incorrect placement of defi nitive clip, we performed intra-operative monitoring of brain tissue oxygen concentration (PtiO(2)), to detect changes in brain oxygenation due to reduced blood fl ow, eventually leading to ischemia, during surgery of middle cerebral artery incidental aneurysms.
PtiO(2) monitoring was performed during surgery of eight patients harboring incidental MCA aneurysms, using a polarographic microcatheter (Licox, GMS - Kiel, Germany), placed in the temporal lobe on the side of the lesion, from dural opening to dural closure.
Basal values varied between 2.3 and 27.3 mmHg; these values are lower than those previously described in the literature as "normal" for uninjured brain or in cases of subarachnoid hemorrhage. In all patients, a significant decrease in PtiO2 was found in every period of temporary clipping of MCA. Post-operative infarction in the territory of middle cerebral artery occurred in one patient and, in that case, there was a persistent minimum value of 0.6 mmHg, without recovery after the placement of the definitive clip. In another patient, an incorrect placement of the definitive clip could be predicted by a decrease in PtiO(2) value.
PtiO(2) monitoring during aneurysm surgery shows brain tissue perfusion in real time and there is a correlation between any episode of reduced blood flow to the affected vascular territory during surgery and a decrease of PtiO2 values. Unexpected low basal values were obtained in "uninjured" brain, with no influence from subarachnoid hemorrhage. The values of risk for brain infarction during temporary arterial occlusion still need further studies, but an incomplete recovery or a persistent fall in PtiO(2) values after definitive clipping should be considered as an indication for verification of the position of the clip.
