E-116 Microsurgically occult sequelae of temporary clip application during cerebral aneurysm surgery – insights from intraoperative cerebral angiography
Year: 2024
Type: conference-abstract
Abstract: Background Temporary artery occlusion is an important technique during the microsurgical repair of cerebral aneurysms. Parent vessel temporary clipping facilitates safe aneurysm dissection and easier mobilization, and may soften the aneurysm turgor for optimal permanent clip application. Microscopically, temporary clip application and removal maneuvers commonly appear insignificant. Despite temporary aneurysm clips having lower closing force than permanent clips, micro-damage to the vessel endothelium has repeatedly been discovered in animal studies. Intraoperative diagnostic cerebral angiography (ioDCA) is a valuable adjunct in aneurysm surgery as it facilitates a full understanding of the aneurysm occlusion status, brain perfusion and parent vessel integrity after temporary clipping. Here, we sought to explore the incidence of temporary clipping induced parent vessel alterations evident on intraoperative cerebral angiography and their clinical sequelae. Methods Consecutive microsurgical cerebral treatments performed between 01/2020 – 06/2023 were retrospectively reviewed (n=148). We included patients >18 years undergoing cerebral aneurysm clipping and immediate ioDCA prior to closure (n=127). We excluded patients without ioDCA and those with angiography after closure (n=11). Independent chart-review was performed by two neurosurgeons: post-operative CTs and MRIs were rigorously evaluated for any ischemic brain injuries. Videos were reviewed to determine microscopic presence of parent vessel injury. Cerebral angiograms were reviewed for presence of parent vessel injury and luminal stenosis quantified if prevalent. Results Collectively, 137 cerebral aneurysms were clipped in 114 patients undergoing 121 craniotomies. Ten patients (7.3%) underwent clipping for an acutely ruptured cerebral aneurysm. Of the 127 elective clippings, 11/127 (8.7%) were previously treated endovascularly. Clinical, radiographic and angiographic median follow-up was 9.4, 14.0 and 6.3 months, respectively. Temporary clipping was performed in 75/137 cases (54.7%). Parent vessel vasospasm was observed in 14/75 (18.7%) with median luminal stenosis of 30% (IQR 25% - 50%) and maximum of 70% stenosis in 3/14 cases. Microscopically, in none (0/14) of these cases, angiographic parent vessel stenosis or other injury was evident. Among the 127 unruptured aneurysm clippings, a total of 12 patients had evidence of parent vessel vasospasm. At discharge, 3/12 vasospasm patients (25%) had an NIHSS change with radiographic ischemic injury compared to 9/115 (7.8%) patients without vasospasm (p=0.087). One patient returned on postoperative day 10 due to aphasia post left middle cerebral artery (MCA) aneurysm clipping. Angiography revealed a distal M1 MCA stenosis compatible with a dissection at the site of previous temporary clip placement which was not evident on ioDCA. With conservative management, the patient fully recovered. At 3 months follow-up, 2.7% of elective aneurysm clippings demonstrated a persistent deficit. Conclusion Immediate intraoperative DCA revealed parent vessel vasospasm in about 18% of cases. Notably, angiographic parent vessel vasospasm was microsurgically occult in all cases. The possible clinical sequala of temporary clipping may be underrecognized. Disclosures J. Oliver: None. G. Weiner: None. A. Chopra: None. O. Goren: 2; C; Microvention. C. Schirmer: None. P. Hendrix: None.
Authors: J Oliver, G Weiner, A Chopra, O Goren, C Schirmer, P Hendrix
Language: English
Subfield: Clinical Neurology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4400893636