Abstract
Recently, the treatment of intracranial aneurysms entered a new phase due to safe surgical tool such as neurophysiologic monitoring and challenged by endovascular treatment. To determine the safety of clipping surgery in the modern era, we reviewed our experiences of simple unruptured anterior circulation aneurysm surgery which is commonly performed in many places. We retrospectively reviewed 610 consecutive patients who were treated with surgical clipping under motor evoked potential (MEP) monitoring for a tiny to large anterior circulation aneurysm in a single institute between 2008 and 2012. MEP changes were identified in 40 cases (6.6 %). MEP deterioration was associated with remote site epidural hematoma (n = 1), anesthesia (n = 2), temporary clipping (n = 21), and permanent clipping (n = 16). Despite that no persistent MEP deterioration was noted after prompt corrective measures, 56 (9.2 %) patients showed symptomatic (n = 14) and asymptomatic (n = 42) radiologic abnormalities. Anterior cerebral artery (ACA) aneurysm was associated with a higher radiologic complication rate (Fisher’s exact test, P < 0.05). Two (0.3 %) patients showed severe morbidity (mRS >2) at latest follow-up. MEP monitoring can be helpful in preventing postoperative motor deterioration but seems to have some limitations. Although the permanent morbidity rate was low, a significant clinical (2.3 %) or radiologic (9.2 %) abnormality rate was identified even in simple aneurysm clipping that should be taken into account when performing interdisciplinary treatment planning and patient counseling. Also, direct vascular monitoring or new neurophysiologic monitoring techniques are needed to reduce surgical complications, especially in ACA aneurysm surgery.
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Bacigaluppi S, Fontanella M, Manninen P, Ducati A, Tredici G, Gentili F (2012) Monitoring techniques for prevention of procedure-related ischemic damage in aneurysm surgery. World Neurosurg 78:276–288. doi:10.1016/j.wneu.2011.11.034
Burns JD, Brown RD Jr (2009) Treatment of unruptured intracranial aneurysms: surgery, coiling, or nothing? Curr Neurol Neurosci Rep 9:6–12
Chamorro A, Marshall RS, Valls-Sole J, Tolosa E, Mohr JP (1997) Motor behavior in stroke patients with isolated medial frontal ischemic infarction. Stroke 28:1755–1760
Dehdashti AR, Binaghi S, Uske A, Regli L (2006) Comparison of multislice computerized tomography and digital substraction angiography in the postoperative evaluation of patients with clipped aneurysms. J Neurosurg 104:395–403
Gerlach R, Beck J, Setzer M, Vatter H, Berkefeld J, Mesnil D, de Rochemont R, Raabe A, Seifert V (2007) Treatment related morbidity of unruptured intracranial aneurysms: results of a prospective single centre series with an interdisciplinary approach over a 6 year period (1999–2005). J Neurol Neurosurg Psychiatry 78:864–871. doi:10.1136/jnnp.2006.106823
Greving JP, Wermer MJ, Brown RD Jr, Morita A, Juvela S, Yonekura M, Ishibashi T, Torner JC, Nakayama T, Rinkel GJ, Algra A (2014) Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. Lancet Neurol 13:59–66. doi:10.1016/S1474- 4422(13)70263-
Higashida RT, Lahue BJ, Torbey MT, Hopkins LN, Leip E, Hanley DF (2007) Treatment of unruptured intracranial aneurysms: a nationwide assessment of effectiveness. AJNR Am J Neuroradiol 28:146–151
Huang MC, Baaj AA, Downes K, Youssef AS, Sauvageau E, van Loveren HR, Agazzi S (2011) Paradoxical trends in the management of unruptured cerebral aneurysms in the United States: analysis of nationwide database over a 10-year period. Stroke 42:1730–1735. doi:10.1161/STROKEAHA.110.603803
Inamasu J, Watabe T, Ganaha T, Yamada Y, Nakae S, Ohmi T, Imizu S, Kaito T, Ito K, Nishiyama Y, Hayashi T, Sano H, Kato Y, Hirose Y (2013) Clinical characteristics and risk factors of chronic subdural haematoma associated with clipping of unruptured cerebral aneurysms. J Clin Neurosci 20:1095–1098. doi:10.1016/j.jocn.2012.09.024
Irie T, Yoshitani K, Ohnishi Y, Shinzawa M, Miura N, Kusaka Y, Miyazaki S, Miyamoto S (2010) The efficacy of motor-evoked potentials on cerebral aneurysm surgery and new-onset postoperative motor deficits. J Neurosurg Anesthesiol 22:247–251. doi:10.1097/ANA.0b013e3181de4eae
Kang SY, Kim JS (2008) Anterior cerebral artery infarction: stroke mechanism and clinical-imaging study in 100 patients. Neurology 70:2386–2393. doi:10.1212/01.wnl.0000314686.94007.d0
Kato Y, Sano H, Dindorkar K, Abe M, Nagahisa S, Iwata S, Yoshida K, Kanno T (2001) Treatment of unruptured intracranial aneurysms—a clinicopathological correlation. Acta Neurochir (Wien) 143:681–686, discussion 687
Kim JE, Lim DJ, Hong CK, Joo SP, Yoon SM, Kim BT (2010) Treatment of unruptured intracranial aneurysms in South Korea in 2006: a nationwide multicenter survey from the Korean society of cerebrovascular surgery. J Korean Neurosurg Soc 47:112–118. doi:10.3340/jkns.2010.47.2.112
Krayenbuhl N, Erdem E, Oinas M, Krisht AF (2009) Symptomatic and silent ischemia associated with microsurgical clipping of intracranial aneurysms: evaluation with diffusion-weighted MRI. Stroke 40:129–133. doi:10.1161/STROKEAHA.108.524777
Lee T, Baytion M, Sciacca R, Mohr JP, Pile-Spellman J (2005) Aggregate analysis of the literature for unruptured intracranial aneurysm treatment. AJNR Am J Neuroradiol 26:1902–1908
Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809–817. doi:10.1016/S0140-6736(05)67214-5
Moman MR, Verweij BH, Buwalda J, Rinkel GJ (2009) Anosmia after endovascular and open surgical treatment of intracranial aneurysms. J Neurosurg 110:482–486. doi:10.3171/2008.8.JNS08761
Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, Nakayama T, Sakai M, Teramoto A, Tominari S, Yoshimoto T (2012) The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med 366:2474–2482. doi:10.1056/NEJMoa1113260
Park J, Lee SH, Kang DH, Kim JS (2009) Olfactory dysfunction after ipsilateral and contralateral pterional approaches for cerebral aneurysms. Neurosurgery 65:727–732. doi:10.1227/01.NEU.0000350225.36099.0B, discussion 732
Sakuma J, Suzuki K, Sasaki T, Matsumoto M, Oinuma M, Kawakami M, Itakura T, Kodama N (2004) Monitoring and preventing blood flow insufficiency due to clip rotation after the treatment of internal carotid artery aneurysms. J Neurosurg 100:960–962. doi:10.3171/jns.2004.100.5.0960
Sonobe M, Yamazaki T, Yonekura M, Kikuchi H (2010) Small unruptured intracranial aneurysm verification study: SUAVe study, Japan. Stroke 41:1969–1977. doi:10.1161/STROKEAHA.110.585059
Takao H, Nojo T (2007) Treatment of unruptured intracranial aneurysms: decision and cost-effectiveness analysis. Radiology 244:755–766. doi:10.1148/radiol.2443061278
Vlak MH, Algra A, Brandenburg R, Rinkel GJ (2011) Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol 10:626–636. doi:10.1016/S1474-4422(11)70109-0
Vlak MH, Rinkel GJ, Greebe P, Algra A (2013) Risk of rupture of an intracranial aneurysm based on patient characteristics: a case-control study. Stroke 44:1256–1259. doi:10.1161/STROKEAHA.111.000679
Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O'Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC (2003) Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103–110
Yeon JY, Seo DW, Hong SC, Kim JS (2010) Transcranial motor evoked potential monitoring during the surgical clipping of unruptured intracranial aneurysms. J Neurol Sci 293:29–34. doi:10.1016/j.jns.2010.03.013
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Jo, KI., Kim, H.R., Yeon, J.Y. et al. Treatment outcomes of surgical clipping for unruptured anterior circulation aneurysm—single institute experiences in the era of neurophysiologic monitoring and endovascular treatment. Neurosurg Rev 38, 677–682 (2015). https://doi.org/10.1007/s10143-015-0642-2
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DOI: https://doi.org/10.1007/s10143-015-0642-2