In clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH), critical steps include clot removal and dissection of aneurysms without premature rupture or brain injuries. To pursue this goal, a piezo actuator-driven pulsed water jet (ADPJ) system was introduced in this study. This study included 42 patients, who suffered aSAH and underwent clipping surgery. Eleven patients underwent surgery with the assistance of the ADPJ system (ADPJ group). In the other 31 patients, surgery was performed without the ADPJ system (Control group). The ADPJ system was used for clot removal and aneurysmal dissection. The clinical impact of the ADPJ system was judged by comparing the rate of premature rupture, degree of clot removal, and clinical outcomes. Intraoperatively, a premature rupture was encountered in 18.2 and 25.8% of cases in the ADPJ and control groups, respectively. Although the differences were not statistically significant, intraoperative observation suggested that the ADPJ system was effective in clot removal and dissection of aneurysms in a safe manner. Computed tomography scans indicated the achievement of higher degrees of clot removal, especially when the ADPJ system was used for cases with preoperative clot volumes of more than 25 ml (p = 0.047, Mann–Whitney U test). Clinical outcomes, including incidence of postoperative brain injury or symptomatic vasospasm, were similar in both groups. We described our preliminary surgical results using the ADPJ system for aSAH. Although further study is needed, the ADPJ system was considered a safe and effective tool for clot removal and dissection of aneurysms.
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The authors appreciate the assistance of Teruko Sueta and Nobuko Hashimoto from the Center for Laboratory Animal Research, Tohoku University for technical assistance. The authors thank Mr. Takeshi Seto, and Mr. Yasuyoshi Hama for preparing surgical instruments. The authors thank Ms. Asaka Ishigamori for administrative assistance. The authors thank Mr. Tomohiro Chiba for quantitative analyses of the blood volume in preoperative and postoperative CT scans. The authors would like to thank Enago (www.enago.jp) for the English review.
Conflicts of interest
Nakagawa and Tominaga received research funding support from Seiko Epson Co., Ltd. under a collaborative research contract with Tohoku University, otherwise none were reported.
Financial support and industry affiliations
This work was supported in part by the Translational Research Network Program from the Japanese Ministry of Education, Culture, Sports, Science, and Technology (MEXT), Grand-in Aid for Scientific Research (C) (26462196/26462197/24592049/26461297/15K10353), Grand-in Aid for Scientific Research (A)(15H01707), (B) (26282116/15H04945). The piezo actuator-driven pulsed water jet system was supplied by Seiko EPSON Corporation as part of a collaborative research contract with Tohoku University.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
Electronic supplementary material
Case 7. Intraoperative video of a right middle cerebral artery aneurysm. With the use of the actuator-driven pulsed water jet (ADPJ) system, a thick subarachnoid hemorrhage was removed. Note that veins or small arteries were not damaged when the water jet directly hit these vessels. Middle cerebral arteries were observed. (MP4 16,297 kb)
Case 4. Intraoperative video of a right middle cerebral artery aneurysm. As the aneurysm was identified, pulsed water jet traced the contours of the aneurysm. Following aneurysmal exposure with the aid of the actuator-driven pulsed water jet system, a permanent clip was safely applied. (MP4 14,000 kb)
Case 10. Intraoperative video of an anterior communicating artery aneurysm approached through right frontotemporal craniotomy. During the use of the actuator-driven pulsed water jet system, premature rupture was encountered. Minor leakage occurred from a dome of the aneurysm embedded in the right frontal lobe. After exposure, a permanent clip was safely applied. (MP4 20,845 kb)
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Endo, H., Endo, T., Nakagawa, A. et al. Application of actuator-driven pulsed water jet in aneurysmal subarachnoid hemorrhage surgery: its effectiveness for dissection around ruptured aneurysmal walls and subarachnoid clot removal. Neurosurg Rev 40, 485–493 (2017) doi:10.1007/s10143-016-0809-5
- Subarachnoid hemorrhage
- Cerebral aneurysms
- Pulsed water jet
- Clot removal
- Sylvian hematoma