Search Results (10)

Background/Objectives: Surgical clipping remains a fundamental treatment modality for intracranial aneurysms, particularly in complex cases and those not amenable to endovascular approaches. However, it is associated with several technical challenges and potential complications that may compromise patient outcomes. This study aims to identify and analyze the most frequent and critical intraoperative pitfalls encountered during microsurgical clipping. We discuss experience-based strategies for avoiding these complications as well as practical solutions for managing them effectively when they occur. Methods: A retrospective review of our institutional experience with surgically treated intracranial aneurysms is reported. The study includes a comprehensive analysis of complications encountered across a defined series of cases, along with representative clinical cases. Results: Several categories of complications were identified, including aneurysm rupture, incomplete clipping and aneurysm remnant, vessel stenosis and brain ischemia, and new-onset seizures. Specific microsurgical techniques, intraoperative tools (e.g., indocyanine-green angiography, neurophysiological monitoring, micro-Doppler flowmetry evaluation), and decision-making algorithms are discussed to help mitigate these risks. For each scenario, tailored rescue strategies are outlined based on both the literature evidence and our clinical experience. Conclusions: Awareness of the potential pitfalls in aneurysm clipping and a structured approach to their prevention and management are crucial for optimizing surgical outcomes, and for preparing young vascular neurosurgeons. Through a combination of technical refinement and scenario-based preparedness, many complications can be anticipated and effectively addressed. Full article

Background and Objectives: To evaluate factors affecting aneurysm rupture, present our surgical experience with intracranial aneurysms, specifically using the picket-fence clipping technique for giant aneurysms, and highlight the complementary roles of sodium fluorescein (Na-Fl) and indocyanine green (ICG) videoangiography in enhancing surgical precision and patient outcomes. Materials and Methods: We retrospectively analyzed 47 patients who underwent microsurgical clipping of intracranial aneurysms with intraoperative Na-Fl and ICG videoangiography between September 2015 and February 2024. We assessed relationships between patient comorbidities, family history of subarachnoid hemorrhage (SAH), smoking history, aneurysm location and size, and SAH occurrence. Concordance between intraoperative videoangiography and postoperative digital subtraction angiography (DSA) for detecting residual aneurysms was also evaluated. Results: Of the 47 patients (31 female, 16 male; mean age 51.78 ± 11.16 years), 11 (23.4%) presented with SAH. The most common aneurysm location was the middle cerebral artery (MCA) (68.1%). Hypertension and smoking history were significantly higher in the hemorrhage group (p < 0.05). Aneurysm size and anterior communicating artery (AComA) location were also significantly associated with hemorrhage (p < 0.05). Aneurysm size demonstrated significant discriminative power for hemorrhage [AUC: 0.884 (0.827–0.941)], with a cutoff of 7.1 mm yielding 90.9% sensitivity and 94.4% specificity. Five giant MCA aneurysms were treated with the picket-fence technique, with intraoperative ICG and Na-Fl confirming parent artery patency and complete aneurysm occlusion, subsequently confirmed by postoperative DSA. Small remnants were detected in 2 cases (4.26%) on postoperative DSA, both in distal ACA aneurysms, which were also detected by intraoperative videoangiography. Conclusions: Hypertension, smoking history, aneurysm size, and location were important predictors of aneurysm rupture. Intraoperative ICG and Na-Fl videoangiography provide real-time, high-resolution visualization crucial for complex intracranial aneurysm surgery, including the picket-fence technique for giant aneurysms. Their complementary use enhances surgical safety, guides intraoperative decision-making, and contributes to improved outcomes in challenging cases. Full article

The aim of this study is to present the outcomes of cerebral aneurysm treatment with the DERIVO^® mini Embolisation Device (DMD), which is compatible with microcatheters with 0.021-inch inner diameters. Consecutive patients treated with DMD were identified retrospectively. Patient and aneurysm characteristics, procedural findings, clinical outcomes and follow-up imaging results were evaluated. A total of 44 target aneurysms in 30 patients were treated with DMD. The mean age of the patients was 49.9 (range, 4–77 years). Four patients with five aneurysms presented with acute subarachnoid hemorrhage. The mean aneurysm size was 6.8 mm (range, 1.5–22 mm). In 29 (65.9%) aneurysms, adjunctive devices were used for endovascular treatment. The overall mortality rate was 3.3% and procedure-related mortality was 0%. Overall neurologic morbidity was 6.6% and none of the patients had a permanent sequela secondary to the procedure. The mean clinical follow-up period was 20.9 months (range, 3 days–46 months) and the mean DSA follow-up period was 10.9 months. A total of 37 (84.1%) aneurysms demonstrated total occlusion (Raymond–Roy [RR 1]); 3 (6.8%) aneurysms had a neck remnant or infundibular filling at the origin of the jailed side branch (RR 2), 4 (9.1%) aneurysms had residual aneurysm filling (RR 3). For those aneurysms treated with bare DMD, the total occlusion rate was 73.3% at a mean follow-up of 16.1 months. In this initial clinical single-center experience, DMD had a good safety profile and efficacy comparable with the currently used flow diverters. Full article

Background/Objectives: Target tetra detachable coils (TTDCs) aid in achieving effective framing during the coil embolization of small intracranial aneurysms by maintaining a tetrahedral conformation within the aneurysm sac. We aimed to report the initial experience of patients treated for intracranial aneurysms using TTDCs, with a specific focus on efficacy and safety. Methods: We retrospectively reviewed the medical records of 41 patients who underwent the coil embolization of intracranial aneurysms sized ≤10 mm with TTDCs between April and May 2023. Post-procedural angiographic and clinical results were reviewed. Results: Of the 46 aneurysms (45 unruptured and 1 ruptured), 33 (71.7%) were treated with the stent-assisted technique and 13 (28.3%) using the simple coil embolization technique. Post-procedural angiography showed complete occlusion in 41 aneurysms (89.1%), neck remnants in 1 (2.2%), and residual aneurysms in 4 (8.7%). The mean packing density was 34.7% (19.3–46.8%), with TTDC coil length comprising a mean of 88.5% of the total coil length. No major device- or procedure-related complications were observed. During the follow-up, 40 aneurysms (93.0%) demonstrated complete occlusion, while neck remnants were observed in 1 (2.3%), and residual aneurysms in 2 (4.7%). No cases of recanalization were observed. Conclusions: The TTDC is a safe and effective device for the endovascular treatment of intracranial aneurysms. Follow-up studies are required to establish long-term results. Full article

(1) Background: Most intracranial aneurysms (IAs) can be treated either with microsurgical clipping or endovascular techniques. In a few cases, simultaneous treatment utilizing both modalities in a hybrid operation room may be favorable. This study analyzes the indication and benefits of a true hybrid approach (tHA) that combines simultaneous endovascular and microsurgical procedures for treatment of IAs in one session. (2) Methods: All patients receiving a true hybrid procedure between 2010 and 2022 in our institution were included. Demographic characteristics, neurological symptoms, pre-interventional treatments, angiographic findings, and postoperative clinical and radiological outcomes were analyzed. Results are discussed in the light of a systematic literature review on reported true hybrid procedures for IA treatment. (3) Results: In total, 10 tHAs were performed. Of these, coiling and concomitant decompressive craniectomy or hematoma evacuation was performed on six occasions. In two patients, multiple IAs were treated with different modalities during the same procedure. In two patients, intraoperative conditions did not allow for complete IA clipping, and the remnant was coiled in the same session. The review of the literature revealed nine papers comprising 58 IAs treated with a tHA. (4) Conclusions: The need for a tHA for IA treatment is rare and limited to highly selective cases. In our experience, tHAs have been most valuable in an emergency setting concerning ruptured IAs. Furthermore, tHAs may also be considered in patients with multiple aneurysms in different vascular territories. Full article

Background: The endovascular treatment of cerebral aneurysms has become widespread but may still be limited by recurrence rates or complications. The discovery of novel embolic strategies may help mitigate these concerns. Methods: We formulated a Photosensitive Hydrogel Polymer (PHP) embolic agent which is low-viscosity, shear-thinning, and radio-opaque. After the filling of an aneurysm with PHP with balloon assistance, we utilized photopolymerization to induce solidification. Different methods of light delivery for photopolymerization were assessed in silicone models of aneurysms and in four acute animal trials with venous anastomosis aneurysms in pigs. Then, balloon-assisted embolization with PHP and photopolymerization was performed in three aneurysms in pigs with a one-month follow-up. Filling volume, recurrence rates, and complications were recorded. Results: The PHP was found to be suitable for the intravascular delivery and treatment of cerebral aneurysms. It was found that light delivery through the balloon catheter, as opposed to light delivery through the injection microcatheter, led to higher rates of filling in the 3D model and acute animal model for cerebral aneurysms. Using the balloon-assisted embolization and light delivery strategy, three wide-necked aneurysms were treated without complication. One-month follow-up showed no recurrence or neck remnants. Conclusions: We demonstrated a novel method of balloon-assisted photosensitive hydrogel polymer embolization and photopolymerization, leading to complete aneurysm filling with no recurrence at 1 month in three wide-necked aneurysms in pigs. This promising methodology will be investigated further with longer-term comparative animal trials. Full article

(1) Background: The aim of this study was to determine the frequency and the pattern of post-procedural intracranial aneurysm contrast enhancement on high-resolution vessel wall magnetic resonance imaging (HR-VW MRI). We investigated the possible association between this imaging finding and factors such as time elapsed since embolization or aneurysm occlusion grade on baseline and follow-up imaging. (2) Methods: Consecutive patients presenting for follow-up after endovascular treatment of intracranial aneurysms were included. HR-VW MRI was acquired and interpreted independently by two radiologists. (3) Results: This study included 40 aneurysms in 39 patients. Contrast enhancement was detected in 30 (75%) aneurysms. It was peripheral in 12 (30.0%), central in 9 (22.5%), and both peripheral and central in 9 (22.5%) aneurysms. The statistical analysis did not reveal any relationship between follow-up period and the presence of contrast enhancement (p = 0.277). There were no statistically significant differences in the frequency of contrast enhancement between aneurysms with total occlusion and those with remnant flow on follow-up MR angiography (p = 0.850) nor between aneurysms with different interval changes in the aneurysm occlusion grade (p = 0.536). Multivariate analysis did not demonstrate aneurysm size, ruptured aneurysm status, nor initial complete aneurysm occlusion to be a predictor of contrast enhancement (p = 0.080). (4) Conclusions: Post-procedural aneurysm contrast enhancement is a common imaging finding on HR-VW MRI. The clinical utility of this imaging finding, especially in the prediction of aneurysm recurrence, seems limited. The results of our study do not support routine use of HR-VW MRI in the follow-up of patients after endovascular treatment of intracranial aneurysms. Full article

Tandem intracranial aneurysms (TandIAs) are rare but inherently complex, and special technical considerations are required for their surgical management. The present case highlights the key surgical aspects of two carotid-ophthalmic TandIAs incidentally found in a 60-year-old female. Both the aneurysms were superiorly projecting, regular in size, and involved the left ophthalmic segment of the internal carotid artery (ICA). The minimum distance between the necks was 3 mm. The patient underwent microsurgery because of the reported major complications rate of the endovascular treatment in the case of a very short minimum distance between the TandIAs. After cervical ICA exposure, both the aneurysms were excluded through a pterional approach. Intradural anterior clinoidectomy and unroofing of the optic canal allowed the mobilization of the left optic nerve. The more distal aneurysm was clipped before the opening of the distal dural ring of the ICA. The proximal aneurysm was clipped with two straight clips stacked perpendicular to the ICA. A small remnant was intentionally left to avoid the stenosis of the ophthalmic artery. Postoperative angiography showed the exclusion of both the aneurysms with a small dog-ear of the more proximal one. The patient was discharged neurologically intact and, after one year, the remnant remained stable. Microsurgical clipping is a definitive and durable treatment for carotid-ophthalmic TandIAs. In the case of a very short minimum distance between the aneurysms, the distal one should be clipped first to make the anterior clinoidectomy, opening of the distal dural ring of the ICA, and clipping of the more proximal aneurysm easier. Full article

Based on the relationship between the posterior clinoid process and the basilar artery (BA) apex it may be difficult to obtain proximal control of the BA using temporary clips. Endovascular BA temporary balloon occlusion (TBO) can reduce aneurysm sac pressure, facilitate dissection/clipping, and finally lower the risk of intraoperative rupture. We present our experience with TBO during aneurysm clipping of posterior circulation aneurysms within the setting of a hybrid operating room (hOR). We report one case each of a basilar tip, posterior cerebral artery, and superior cerebellar artery aneurysm that underwent surgical occlusion under TBO within an hOR. Surgical exposure of the BA was achieved with a pterional approach and selective anterior and posterior clinoidectomy. Intraoperative digital subtraction angiography (iDSA) was performed prior, during, and after aneurysm occlusion. Two patients presented with subarachnoid hemorrhage and one patient presented with an unruptured aneurysm. The intraluminal balloon was inserted through the femoral artery and inflated in the BA after craniotomy to allow further dissection of the parent vessel and branches needed for the preparation of the aneurysm neck. No complications during balloon inflation and aneurysm dissection occurred. Intraoperative aneurysm rupture prior to clipping did not occur. The duration of TBO varied between 9 and 11 min. Small neck aneurysm remnants were present in two cases (BA and PCA). Two patients recovered well with a GOS 5 after surgery and one patient died due to complications unrelated to surgery. Intraoperative TBO within the hOR is a feasible and safe procedure with no additional morbidity when using a standardized protocol and setting. No relevant side effects or intraoperative complications were present in this series. In addition, iDSA in an hOR facilitates the evaluation of the surgical result and 3D reconstructions provide documentation of potential aneurysm remnants for future follow-up. Full article

There are several unique features of the concept of advanced intraoperative imaging modalities with CT (computed tomography), MRI (magnet resonance imaging) and DSA (digital substraction angiography) inaugurated in one operating tract. For the first time, there is the opportunity to switch from postoperative to intraoperative imaging – when the surgeon can not only check the result of surgery but improve it – but in general, that is, for all specialties, at least theoretically. Intraoperative imaging is a broad term with many technologies already in routine use today, such as image intensifier, ultrasound, fluorescence technologies, and soon. Using intra-operative CT, MRI, and DSA is not indisputable. Does the benefit justify such immense costs, both in building and in maintenance? To evaluate the clinical benefit and possible drawbacks of these technologies and if there's a substantial benefit for the patients. Also, this is a review of literature to evaluate the evidence and clinical impact of advanced intraoperative imaging in neurosurgery. There is one prospective randomized trial showing that intraoperative MRI increases the extent of resection. In spine surgery, there are several randomized trials showing that pedicle screws are inserted more accurately when image guidance is used. However, there is no RCT comparing navigation with intraoperative CT-updated navigation. Several prospective studies are showing that intraoperative DSA is able to identify vascular remnants or vessel occlusions in case of aneurysm-, arteriovenous malformation-and arteriovenous fistula-surgery. A fair comparison of the benefit of these new technologies must take into consideration that other methods of intraoperative imaging or image guidance already exist. Hence, there are some patients in whom the use of the more advanced technologies makes a personal, individual difference that may affect quality of life and survival. We have to differentiate between (1) the best diagnostic procedure and (2) the term “standard of care.” Advanced intraoperative imaging is a gold standard in terms of imaging but not a standard of care. Full article