Introduction
Methods
National survey regarding the use of imaging
Retrospective study evaluating intraoperative assessment
Research design and inclusion criteria
Data collection
Definitions of outcome measures
Statistical analysis
Results
National survey regarding intraoperative and postoperative imaging
Retrospective study evaluating intraoperative assessment
Patient population
Characteristic | Value (%) |
---|---|
Age (years) | |
Mean ± SD | 55.3 ± 13.2 |
Range | 12–79 |
Gender male | 26 (24.5) |
Presenting with SAH | 69 (65.1) |
WFNS grade at arrival in hospital | 1: 39 (56.5) |
2: 8 (11.6) | |
3: 3 (4.3) | |
4: 8 (11.6) | |
5: 11 (15.9) | |
HH grade at arrival in hospital | 1: 15 (21.7) |
2: 27 (39.1) | |
3: 11 (15.9) | |
4: 10 (14.5) | |
5: 6 (8.7) | |
Number of clipped aneurysms per patient | |
One aneurysm | 84 (79.2) |
Two aneurysms | 18 (17.0) |
Three aneurysms | 4 (3.8) |
Risk factors aneurysm formation | |
Hypertension | 40 (37.7) |
Tobacco abuse | 41 (38.7) |
Alcohol abuse | 12 (11.3) |
Drug abuse | 4 (3.8) |
Positive family history of intracranial aneurysms | 6 (5.7) |
History of SAH | 3 (2.8) |
Characteristic | Value (%) |
---|---|
Location | |
ACA (excluding ACoA) | 9 (6.8) |
AChA | 8 (6.1) |
ACoA | 20 (15.2) |
ICA | 6 (4.5) |
MCA | 67 (50.8) |
PCoA | 18 (13.6) |
PICA | 3 (2.3) |
VA | 1 (0.8) |
Ruptured | 66 (50.0) |
Unruptured | 66 (50.0) |
Of which clipped in emergency setting | 23 (34.8) |
Rebleed after clipping | 0 |
Residuals
Characteristic | Value (%) |
---|---|
Location | |
AChA | 2 (8.7) |
ACoA | 7 (30.4) |
MCA | 9 (39.1) |
PCoA | 5 (21.7) |
Size | |
Median (IQR) | 1.5 (1.2–2.5) |
Range | 1.0–14.0 |
Ruptured aneurysm | 17 (73.9) |
Unruptured aneurysm | 6 (26.1) |
Of which clipped in emergency setting | 2 (33.3) |
Evaluation of intraoperative assessment and postoperative angiography
Postoperative DSA | Total | |||
---|---|---|---|---|
R ≥ 1 | R = 0 or R < 1 | |||
Operative report | ExpY or ExpI | 13 | 15 | 28 |
ExpN | 10 | 94 | 104 | |
Total | 23 | 109 | 132 |
Clinical consequences of the residuals
Subgroup analysis
Case presentations
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Case 1. A 54-year-old woman presented with SAH, WFNS grade 1. DSA revealed a 3.7 mm, broad-based, posterior communicating artery (PCoA) aneurysm. The aneurysm was clipped and, based on the operative report, the neurosurgeon did not expect a residual. After the operation, the patient suffered from bradyphrenia due to vasospasm, for which induced hypertension was initiated on the intensive care unit. Postoperative DSA was performed 5 days later, showing residual filling of the aneurysm and severe angiographic vasospasm. The residual aneurysm was 2.3 mm in size (R ≥ 1). Within 2 days, the aneurysm was successfully coiled. DSA images of this patient are shown in Fig. 2.
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Case 2. A 67-year-old woman arrived in the hospital with SAH, WFNS grade 1. CTA revealed a lobulated, 14.0 mm, PCoA aneurysm in the context of a fetal origin of the posterior cerebral artery. The aneurysm was clipped. In his operative report, the neurosurgeon reported multiple problems during surgery and finally described “almost complete occlusion” of the aneurysm. Surprisingly, postoperative DSA demonstrated complete, albeit slowed, filling of the entire aneurysm through a small remaining channel at the level of the aneurysm neck. Successful re-clipping followed the next day. Key images are shown in Fig. 3.
Discussion
Routine clinical protocols for post clipping imaging
Predictive value of intraoperative assessment
Authors and year | Aneurysms | % Residuals |
---|---|---|
Acevedo et al. (1997) [1] | 267 | 6.3 |
Akyüz et al. (2002) [2] | 186 | 7.0 |
Akyüz et al. (2004) [3] | 166 | 4.2 |
Bernat et al. (2017) [4] | 37 | 24.3* |
Brown et al. (2017) [5] | 758 | 7.8 |
Burkhardt et al. (2017) [6] | 346 | 4.6 |
David et al. (1999) [9] | 147 | 8.2 |
Dellaretti et al. (2017) [11] | 105 | 13.3 |
Feuerberg et al. (1987) [13] | 715 | 3.9 |
Hollin et al. (1973) [15] | 55 | 5.5 |
Kivisaari et al. (2004) [16] | 808 | 12.0 |
Le Roux et al. (1998) [18] | 637 | 5.7 |
Macdonald et al. (1993) [19] | 78 | 10.3 |
Meyer et al. (2004) [20] | 384 | 4.9 |
Proust et al. (1997) [22] | 44 | 2.3 |
Rauzzino et al. (1998) [23] | 312 | 4.2 |
Sindou et al. (1998) [24] | 305 | 5.9 |