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Role of endoscopy in multi-modality monitoring during aneurysm surgery: A single center experience with 175 consecutive unruptured aneurysms.

Yamada Y, Kato Y, Ishihara K, Ito K, Kaito T, Nouri M, Oheda M, Inamasu J, Hirose Y - Asian J Neurosurg (2015 Jan-Mar)

Bottom Line: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years.In selected cases, motor evoked potential monitoring was implemented.No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan.

ABSTRACT

Objective and background: Unruptured aneurysm surgery is a challenge to all vascular neurosurgeons as the patient is asymptomatic and no even slight neurological deficits should be expected postoperatively. To this aim, multi-modality checking of the vessels during the surgery is highly recommended to assure of the patency of the parent and perforator arteries next to an aneurysm. In this paper, we present our experience in the last 1.5 years with emphasis on the role of endoscope assisted microsurgery.

Methods: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years. All patients underwent endoscope assisted microsurgery with pre- and post-clipping indocyanine green angiography. In selected cases, motor evoked potential monitoring was implemented.

Results: No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively. Our illustrative cases show how endoscopy may help the surgeon to visualize hidden vessels behind and medial to an aneurysm.

Conclusions: Our results indicated that multi-modality monitoring during unruptured aneurysm surgeries is associated with excellent outcome. Endoscope is able to show blind corners during aneurysm surgery which cannot be routinely observed with microscope and its application in aneurysm surgery assists the surgeon to make certain of complete neck clipping and preservation of perforating arteries around the aneurysm.

No MeSH data available.


Related in: MedlinePlus

(a) Internal carotid artery choroidal segment aneurysm in 71-year-old man [case 5 in Table 3]. (b) Intra-operative view of the aneurysm and (c) the same view after fluorescence angiography. (d) Endoscopic view showing the perforators behind the aneurysm. (e) Clipping of the aneurysm and (f) postaneurysm clipping demonstrating perforators. The patient recovered fully from the anesthesia when 6 h later he developed contra-lateral incomplete hemiparesis which despite aggressive medical therapy turned into a complete hemiplegia after 36 h
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Figure 2: (a) Internal carotid artery choroidal segment aneurysm in 71-year-old man [case 5 in Table 3]. (b) Intra-operative view of the aneurysm and (c) the same view after fluorescence angiography. (d) Endoscopic view showing the perforators behind the aneurysm. (e) Clipping of the aneurysm and (f) postaneurysm clipping demonstrating perforators. The patient recovered fully from the anesthesia when 6 h later he developed contra-lateral incomplete hemiparesis which despite aggressive medical therapy turned into a complete hemiplegia after 36 h

Mentions: In spite of normal monitoring after clipping, sometimes a postoperative neurological deficit happens. Distal emboli during the vascular manipulation, irreversible brain ischemia due to prolonged proximal closure or permanent damage of perforators due to a misplaced clip can be the underlying causes. However, we still do not know whether discovering these events (i.e., emboli or irreversible ischemia) intra-operatively improves the outcome. To overcome these obstacles, we use intraoperative MEP especially when there is a high risk of distal emboli (e.g., severe atherosclerosis of the parent artery) or the aneurysm is placed in proximity to numerous perforators (e.g., proximal MCA aneurysms). This is in concordance with the studies reporting more difficult clipping and worse outcome for atherosclerotic calcified aneurysms.[3233] Vasospasm of a major or perforating artery can be another source of postoperative deficits despite a safe and uneventful clipping of the aneurysm [case 5 in Table 3] [Figure 2]. Although rare, but isolated symptomatic perforators vasospasm has been reported and it further signifies the importance of these vessels.[34] Current technology does not offer surgeons an opportunity to monitor and prevent arterial spastic events during the operation, and in fact, the vasospasm related infarction develops in the postoperative period in most cases. In spite of aggressive medical or interventional management, the functional outcome is usually poor in this situation.


Role of endoscopy in multi-modality monitoring during aneurysm surgery: A single center experience with 175 consecutive unruptured aneurysms.

Yamada Y, Kato Y, Ishihara K, Ito K, Kaito T, Nouri M, Oheda M, Inamasu J, Hirose Y - Asian J Neurosurg (2015 Jan-Mar)

(a) Internal carotid artery choroidal segment aneurysm in 71-year-old man [case 5 in Table 3]. (b) Intra-operative view of the aneurysm and (c) the same view after fluorescence angiography. (d) Endoscopic view showing the perforators behind the aneurysm. (e) Clipping of the aneurysm and (f) postaneurysm clipping demonstrating perforators. The patient recovered fully from the anesthesia when 6 h later he developed contra-lateral incomplete hemiparesis which despite aggressive medical therapy turned into a complete hemiplegia after 36 h
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4352638&req=5

Figure 2: (a) Internal carotid artery choroidal segment aneurysm in 71-year-old man [case 5 in Table 3]. (b) Intra-operative view of the aneurysm and (c) the same view after fluorescence angiography. (d) Endoscopic view showing the perforators behind the aneurysm. (e) Clipping of the aneurysm and (f) postaneurysm clipping demonstrating perforators. The patient recovered fully from the anesthesia when 6 h later he developed contra-lateral incomplete hemiparesis which despite aggressive medical therapy turned into a complete hemiplegia after 36 h
Mentions: In spite of normal monitoring after clipping, sometimes a postoperative neurological deficit happens. Distal emboli during the vascular manipulation, irreversible brain ischemia due to prolonged proximal closure or permanent damage of perforators due to a misplaced clip can be the underlying causes. However, we still do not know whether discovering these events (i.e., emboli or irreversible ischemia) intra-operatively improves the outcome. To overcome these obstacles, we use intraoperative MEP especially when there is a high risk of distal emboli (e.g., severe atherosclerosis of the parent artery) or the aneurysm is placed in proximity to numerous perforators (e.g., proximal MCA aneurysms). This is in concordance with the studies reporting more difficult clipping and worse outcome for atherosclerotic calcified aneurysms.[3233] Vasospasm of a major or perforating artery can be another source of postoperative deficits despite a safe and uneventful clipping of the aneurysm [case 5 in Table 3] [Figure 2]. Although rare, but isolated symptomatic perforators vasospasm has been reported and it further signifies the importance of these vessels.[34] Current technology does not offer surgeons an opportunity to monitor and prevent arterial spastic events during the operation, and in fact, the vasospasm related infarction develops in the postoperative period in most cases. In spite of aggressive medical or interventional management, the functional outcome is usually poor in this situation.

Bottom Line: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years.In selected cases, motor evoked potential monitoring was implemented.No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Fujita Health University Hospital, Toyoake, Aichi, Japan.

ABSTRACT

Objective and background: Unruptured aneurysm surgery is a challenge to all vascular neurosurgeons as the patient is asymptomatic and no even slight neurological deficits should be expected postoperatively. To this aim, multi-modality checking of the vessels during the surgery is highly recommended to assure of the patency of the parent and perforator arteries next to an aneurysm. In this paper, we present our experience in the last 1.5 years with emphasis on the role of endoscope assisted microsurgery.

Methods: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years. All patients underwent endoscope assisted microsurgery with pre- and post-clipping indocyanine green angiography. In selected cases, motor evoked potential monitoring was implemented.

Results: No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively. Our illustrative cases show how endoscopy may help the surgeon to visualize hidden vessels behind and medial to an aneurysm.

Conclusions: Our results indicated that multi-modality monitoring during unruptured aneurysm surgeries is associated with excellent outcome. Endoscope is able to show blind corners during aneurysm surgery which cannot be routinely observed with microscope and its application in aneurysm surgery assists the surgeon to make certain of complete neck clipping and preservation of perforating arteries around the aneurysm.

No MeSH data available.


Related in: MedlinePlus