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Results of re-exploration because of compromised distal blood flow after clipping unruptured intracranial aneurysms

  • Clinical Article - Vascular
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Abstract

Background

One of the major causes for performing unplanned re-exploration of a craniotomy after microsurgery for unruptured intracranial aneurysms (UIAs) is compromised distal blood flow after clipping. Therefore, it is important to identify the causes of compromised distal blood flow after clipping and the factors that influence the prognosis for re-exploration in order to decrease ischemic complications related to clipping UIAs.

Method

Between January 2007 and December 2013, 1954 patients underwent microsurgery for UIAs. In this cohort, 20 patients (1.0 %) required unplanned re-exploration of the craniotomy for several reasons, and 11 patients (0.6 %) underwent unplanned re-exploration with clip repositioning or changing of the previous clip because of compromised distal blood flow after clipping. Patient characteristics, aneurysm properties, intraoperative findings, annual incidence and prognosis were analyzed in these 11 patients.

Results

The annual incidence of re-exploration has gradually decreased since the introduction of several intraoperative monitoring techniques. In total, 3.0 % of UIAs in the M1 trunk, 0.8 % of UIAs at the origin of the anterior choroidal artery (AchA) and 0.5 % of UIAs at the bifurcation of the middle cerebral artery (MCA) required re-exploration. Here, all 11 UIAs had broad necks, and atherosclerosis was identified around 10 UIAs. Six patients with compromised MCA flow demonstrated relatively better outcomes following re-exploration than five patients with a compromised lenticulostriate artery (LSA) or AchA flow. Four patients with delayed ischemic symptoms demonstrated relatively better outcomes than the seven patients who developed ischemic symptoms immediately postoperatively.

Conclusion

Clinicians need to be more careful not to compromise distal blood flow when clipping UIAs at the MCA and AchA origin. Various intraoperative monitoring techniques can help reduce the incidence of compromised distal blood flow after clipping.

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Conflict of interest

All authors listed on the title page certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

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Authors and Affiliations

  1. Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736 l, South Korea

    Wonhyoung Park, Jae Sung Ahn, Sung Ho Lee, Jung Cheol Park & Byung Duk Kwun

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  1. Wonhyoung Park
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  2. Jae Sung Ahn
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Correspondence to Jae Sung Ahn.

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Comments

Among their impressive series of operated unruptured intracranial aneurysms, the authors present 11 cases that were re-explored because of compromised distal blood flow immediately postoperatively. Although without any doubt these represent negative incidents, they were managed promptly, and most cases eventually had a favorable outcome.

In unruptured aneurysm surgery, local brain conditions are usually calm and can mislead the surgeon following an uneventful clip placement. Intraoperative techniques such as angiography and neurophysiology are extremely important and should be an integral part of aneurysm surgery in particular when dealing with middle cerebral artery aneurysms. Additionally, largely dependent on the surgeon’s judgment and experience, correct clip positioning, placement of multiple clips, or opening plus resection of the aneurysm sac especially for large middle cerebral aneurysms can help avoid such events.

Even in experienced hands and in large centers, compromised blood flow immediately after aneurysm surgery is still a reality and can be easily missed. Special emphasis should be placed on the prevention of such events. Restricted flow in anterior choroidal and lenticulostriate arteries can frequently lead to irreversible neurologic sequelae and is associated with worse prognosis. Besides surgeon’s skills and experience, the implementation of more advanced intraoperative neuroimaging techniques will likely further reduce the need for reoperation and improve outcomes.

Parmenion Tsitsopoulos

Uppsala, Sweden

When planning clipping of an unruptured cerebral aneurysm, the neck length and potential calcifications must be analyzed beforehand to help in choosing the right clip(s) and informing the scrub nurse. The length of the clip blades should be a minimum of 1.5 times the length of the neck for perfect fit. Too short a blade (1) may lead to filling of the aneurysm, and too long a blade may cause inadvertent kinking of the parent artery and closure of the adjacent arteries with ischemic sequelae. When calcifications are in the neck, a stronger (= longer) clip may be needed or preferably more than one with the optimal length to avoid clip slipping—this may cause either compromised blood flow, like in the present series, or filling of the neck. Also, using temporary clips before clipping and puncturing of the aneurysm after clipping to soften it for less pressure and resistance of the neck facilitates proper and permanent positioning of the blades. In giant calcified aneurysms, a vascular clamp may be used to assist clipping (2). After clipping and observation under the operative microscope, ICG angiography (3) and Doppler US will be performed together with flow measurements if possible followed by CT angiography the next day at our department or DSA in case of complex giant aneurysms. In case of neurological deficits after waking up the patient, these studies should be performed immediately to allow quick repositioning of the clip when indicated.

1. Celik O, Niemelä M, Romani R, Hernesniemi J: Inappropriate application of Yasargil aneurysm clips: a new observation and technical remark. Neurosurgery 66:84–87, 2010

2. Navratil O, Lehecka M, Lehto H, Dashti R, Kivisaari R, Niemelä M, Hernesniemi JA: Vascular clamp-assisted clipping of thick-walled giant aneurysms. Neurosurgery 64:113–20, 2009

3. Dashti R, Laakso A, Niemelä M, Porras M, Hernesniemi J. Microscope-integrated ner-infrared indocyanine green videoangiography during surgery of intracranial aneurysms: the Helsinki experience. Surg Neurol 71 (5):543–50, 2009

Mika Niemelä

Helsinki,Finland

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Park, W., Ahn, J.S., Lee, S.H. et al. Results of re-exploration because of compromised distal blood flow after clipping unruptured intracranial aneurysms. Acta Neurochir 157, 1015–1024 (2015). https://doi.org/10.1007/s00701-015-2408-6

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