DOI: https://doi.org/10.25305/unj.176513

Intraoperative aneurysm rupture — the main complication in microsurgery of cerebral aneurysms

Artur V. Byndiu, Mikhail Y. Orlov, Maksim V. Yeleynik, Svetlana O. Lytvak

Abstract


Objective: To analyze the impact of the intraoperative risk factors of intraoperative aneurysm rupture (IAR) and IRA in clipping a brain aneurysm on the results of surgical treatment.

Materials and methods. A retrospective analysis of surgical treatment of 138 (11.4 %) patients, with IAR during clipping of a brain aneurysm in the period from 2011 to 2017, was performed. The total number of operations for clipping cerebral aneurysms in our observations is 1,208 (100 %). Preoperative examination of patients included clinical and neurological examination, brain CT, cerebral angiography (CAG), duplex scan of the main vessels of the head and neck. The radicality of clipping was controlled by puncture of the aneurysmal dome, using intraoperative Doppler and postoperative CAG.

Results. IAR occurred at all stages of surgery preceding the exclusion of an aneurysm from the bloodstream, but prevailed in its isolation and clipping. Non-contact arterial aneurysm (AA) rupture was observed in 6 (4.35 %) patients. Ischemic lesions according to postoperative MSCT of the brain were observed in 2 (1.45 %) patients with noncontact intraoperative ruptures of AA MCA on the right. The contact intraoperative rupture of AA was observed in 132 (95.65 %) cases. The results of treatment were evaluated at hospital discharge on the Glasgow scale results, according to which we received the following data: 5 points — 67 patients (48.55 %); 4 points — 17 (12.32 %); 3 points — 37 (26.81 %); 2 points — 0; 1 point — 17 (12.32 %) cases.

Conclusions:

1. Intraoperative rupture brain aneurysm is the most common intraoperative complication, which threatens massive blood loss during surgery, forces the surgeon to change surgical tactics and often perform aggressive manipulations, such as forced temporal clipping.

2. Analyzing the surgical interventions of clipping of cerebral AA in which IAR took place, the most common risk factors for IAR were found to be brain swelling, large AA, atherosclerotic changes of cerebral vessels, high blood pressure during surgery, pronounced arachnoid changes.

3. According to our observations data, most of the IARs occurred with AA of the ACA-ACoA complex (84 cases — 60.87 %), which is related to hemodynamic features, anatomic variability of the ACA-ACoA complex and frequent localization of AA in this area.

4. In our study, IAR occurs more frequently at the stage of AA excretion (116 cases — 84.06 %) and directly during AA clipping (7 cases — 5.07 %); less frequently — at the stage of AA artery extraction (6 — 4.35 %), at the stage of early arachnoid dissection (3 — 2.17 %) and at the craniotomy stage — non-contact IAR (6 — 4.35 %).


Keywords


arterial aneurysm; intraoperative complications; subarachnoid hemorrhage; intraoperative aneurysm rupture

References


1. Lai LT, O’Neill AH. History, Evolution, and Continuing Innovations of Intracranial Aneurysm Surgery. World Neurosurg. 2017 Jun;102:673-681. [CrossRef] [PubMed]

2. Acciarri N, Toniato G, Raabe A, Lanzino G. Clipping techniques in cerebral aneurysm surgery. J Neurosurg Sci. 2016 Mar;60(1):83-94. [PubMed]

3. Lawton MT, Du R. Effect of the neurosurgeon’s surgical experience on outcomes from intraoperative aneurysmal rupture. Neurosurgery. 2005 Jul;57(1):9-15; discussion 9-15. [CrossRef] [PubMed]

4. Liu Q, Jiang P, Wu J, Gao B, Wang S. The Morphological and Hemodynamic Characteristics of the Intraoperative Ruptured Aneurysm. Front Neurosci. 2019 Mar 26;13:233. [CrossRef] [PubMed] [PubMed Central]

5. Tian Z, Zhang Y, Jing L, Liu J, Zhang Y, Yang X. Rupture Risk Assessment for Mirror Aneurysms with Different Outcomes in the Same Patient. Front Neurol. 2016 Dec 5;7:219. [CrossRef] [PubMed] [PubMed Central]

6. Choque-Velasquez J, Hernesniemi J. Microsurgical clipping of a large ruptured anterior communicating artery aneurysm. Surg Neurol Int. 2018 Nov 28;9:233. [CrossRef] [PubMed] [PubMed Central]

7. Dzyak LA, Zorin NA, Golik VA, Skrabets Yu. [Arterial aneurysms and arteriovenous malformations of the brain]. Dnepropetrovsk: Porogi, 2003. Russian.

8. Krylov VV, Prirodov AV. Risk factors of surgical treatment for middle cerebral artery aneurysms in acute period of subarachnoid hemorrhage. The Russian Journal of Neurosurgery. 2011;(1):31-41. Russian. Available from: https://elibrary.ru/item.asp?id=16449822

9. Kheireddin AS, Filatov IuM, Belousova OB, Pilipenko IuV, Zolotukhin SP, Sazonov IA, Zarzur KhKh. [Intraoperative rupture of cerebral aneurysm--incidence and risk factors]. Zh Vopr Neirokhir Im N N Burdenko. 2007 Oct-Dec;(4):33-8; discussion 38. Russian. [PubMed]

10. Lakićević N, Vujotić L, Radulović D, Cvrkota I, Samardžić M. Factors Influencing Intraoperative Rupture of Intracranial Aneurysms. Turk Neurosurg. 2015;25(6):858-85. [CrossRef] [PubMed]

11. Leipzig TJ, Morgan J, Horner TG, Payner T, Redelman K, Johnson CS. Analysis of intraoperative rupture in the surgical treatment of 1694 saccular aneurysms. Neurosurgery. 2005 Mar;56(3):455-68; discussion 455-68. [CrossRef] [PubMed]

12. Nanda A, Vannemreddy P. Management of intracranial aneurysms: factors that influence clinical grade and surgical outcome. South Med J. 2003 Mar;96(3):259-63. [CrossRef] [PubMed]

13. Lin TK, Hsieh TC, Tsai HC, Lu YJ, Lin CL, Huang YC. Factors associated with poor outcome in patients with major intraoperative rupture of intracranial aneurysm. Acta Neurol Taiwan. 2013 Sep;22(3):106-11. [PubMed]

14. Lawton MT, Du R. Effect of the neurosurgeon’s surgical experience on outcomes from intraoperative aneurysmal rupture. Neurosurgery. 2005 Jul;57(1):9-15; discussion 9-15. [CrossRef] [PubMed]

15. Liu Q, Jiang P, Wu J, Gao B, Wang S. The Morphological and Hemodynamic Characteristics of the Intraoperative Ruptured Aneurysm. Front Neurosci. 2019 Mar 26;13:233. [CrossRef] [PubMed] [PubMed Central]

16. Forget TR Jr, Benitez R, Veznedaroglu E, Sharan A, Mitchell W, Silva M, Rosenwasser RH. A review of size and location of ruptured intracranial aneurysms. Neurosurgery. 2001 Dec;49(6):1322-5; discussion 1325-6. [CrossRef] [PubMed]

17. Kopitnik TA, Horowitz MB, Samson DS. Surgical management of intraoperative aneurysm rupture. In: Schmidek HH, Sweet WH, editors. Schmidek & Sweet’s Operative Neurosurgical Techniques: Indications, Methods, and Results. 4th ed. Philadelphia: WB Saunders Co; 2000. p. 1275–1281.

18. Chen SF, Kato Y, Kumar A, Tan GW, Oguri D, Oda J, Watabe T, Imizu S, Sano H, Wang ZX. Intraoperative rupture in the surgical treatment of patients with intracranial aneurysms. J Clin Neurosci. 2016 Dec;34:63-69. [CrossRef] [PubMed]

19. Lawton MT, Du R. Effect of the neurosurgeon’s surgical experience on outcomes from intraoperative aneurysmal rupture. Neurosurgery. 2005 Jul;57(1):9-15; discussion 9-15. [CrossRef] [PubMed]

20. Weir B, Disney L, Karrison T. Sizes of ruptured and unruptured aneurysms in relation to their sites and the ages of patients. J Neurosurg. 2002 Jan;96(1):64-70. [CrossRef] [PubMed]

21. Della Puppa A, Rossetto M, Volpin F, Rustemi O, Grego A, Gerardi A, Ortolan R, Causin F, Munari M, Scienza R. Microsurgical Clipping of Intracranial Aneurysms Assisted by Neurophysiological Monitoring, Microvascular Flow Probe, and ICG-VA: Outcomes and Intraoperative Data on a Multimodal Strategy. World Neurosurg. 2018 May;113:e336-e344. [CrossRef] [PubMed]


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