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  • Intraoperative cerebral angiography reveals microsurgically occult sequelae of temporary clip application during elective cerebral aneurysm surgery

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Open surgery
Case series
Intraoperative cerebral angiography reveals microsurgically occult sequelae of temporary clip application during elective cerebral aneurysm surgery
  1. Philipp Hendrix1,
  2. Sina Hemmer1,
  3. Anant Chopra2,
  4. Oded Goren1,
  5. Gregory M Weiner3,
  6. Clemens M Schirmer3,
  7. Jeffrey D Oliver1
    1. 1Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
    2. 2Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
    3. 3Department of Neurosurgery, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania, USA
    1. Correspondence to Dr Philipp Hendrix; hendrix.philipp{at}gmail.com

    Abstract

    Background Temporary clipping (TC) is an essential adjunct in cerebral aneurysm (CA) surgery. Despite appearing insignificant to the surgeon under the microscope, TC may cause parent vessel injury. Intraoperative diagnostic cerebral angiography (ioDCA) is crucial for assessing aneurysm occlusion and parent vessel integrity. We aimed to assess sequelae of TC evident on immediate ioDCA.

    Methods Elective CA clippings with ioDCA in a hybrid operating room from January 2020 to June 2023 were reviewed. Microsurgical and angiographic assessments were performed to identify post-TC parent vessel alterations. Outcomes were compared between TC and non-TC-groups.

    Results Collectively, 107 patients underwent 111 craniotomies for clipping of 127 CAs. TC was used in 59/111 cases (53.2%) for treatment of 66/127 CAs (51.9%). CA size and neck were significantly larger in the TC group than in the non-TC group (p<0.001). Parent vessel vasospasm at the site of the previous temporary clip location was evident on 3D rotational angiography in 12/59 (20.3%) TC cases. Clip adjustment rates after ioDCA were similar between groups (TC 13.6% vs non-TC 8.2%, p=0.328). In the TC group compared with the non-TC group, the rates of symptomatic radiographic ischemia and functional decline at discharge were significantly higher (p=0.022 and p=0.045, respectively). However, functional status at follow-up was comparable (p=0.620).

    Conclusions TC during CA surgery can cause significant yet microsurgically occult vasospasm in the parent vessel, potentially contributing to symptomatic ischemia and early functional decline. Intraoperative angiography is crucial for detecting this issue, highlighting both its importance and the risks associated with TC.

    • Aneurysm
    • Angiography

    https://doi.org/10.1136/jnis-2024-022349

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      Footnotes

      • Contributors Guarantor: PH. Study conception and design: PH. Data collection: all authors. Analysis and interpretation of results: PH, JDO. Draft manuscript preparation: PH, JDO. Final draft: PH. All authors reviewed the results, critically revised and approved the final version of the manuscript.

      • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      • Competing interests None declared.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.