Elective Intermittent Temporary Clipping in Aneurysm Surgery: A Practical Protocol

✓ Advances in anesthetic and surgical management, such as induced deep hypothermic circulatory arrest and application of temporary clips, have improved outcome for patients with basilar artery aneurysms. Nonetheless, these techniques are associated with significant risks. The authors report a case in which three transient periods of cardiac asystole were induced during basilar artery aneurysm surgery. Adenosine-induced asystole facilitated the safe clipping of the aneurysm by producing consistent periods of profound hypotension and collapse of the aneurysm without the need for temporary clipping. This technique provided unencumbered identification of perforating arteries, precise definition of the local anatomy, and an ideal environment for the safe placement of the aneurysm clip.

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Temporary Clipping in Intracranial Aneurysm Surgery

Rivista di Neuroradiologia ◽

10.1177/197140090201500513 ◽

2002 ◽

Vol 15 (5) ◽

pp. 579-582

Author(s):

C. Bellotti ◽

G. Panzarasa ◽

M. Arrigoni ◽

P.G. Car ◽

G. Allegra ◽

...

Keyword(s):

Blood Pressure ◽

Intracranial Aneurysm ◽

Surgical Complications ◽

Aneurysm Surgery ◽

Mortality And Morbidity ◽

Occlusion Time ◽

Arterial Circulation ◽

Complex Aneurysms ◽

Clinical Complications ◽

Temporary Clipping

The intra-operative rupture of intracranial aneurysms (IA) occurs in 5–30% of cases as reported in the literature. This event is frequently associated with an increase in mortality and morbidity. The aim of this study was to evaluate the prognostic importance of temporary clipping in intracranial aneurysm surgery. A series of 304 cases of IA treated surgically were selected by excluding giant or Hunt-Hess grade >3 aneurysms. Two groups of patients were compared: one of 157 cases that had temporary clipping (TC) during surgery and the other of 147 patients who did not have TC. The neuroprotective measures used were the infusion of Thiopental and maintenance of adequate blood pressure by use of Bitartrate Metaraminol and Ephedrine. The surgical complications, chiefly intra-operative rupture of the sac and consequences of malpositioning the clip with associated clinical complications, were considered. The two groups were compared using χ2 that showed a statistically significant reduction of the surgical complications in those patients who had TC. The associated poor clinical outcome was reduced from 7.5% to 2.5%. The main prognostic factor in determining the ischemic damage was the occlusion time of the local arterial circulation. The mean occlusion time in these patients was limited to four minutes and in only 12 cases reached 15–16 minutes without ischemic complications. Temporary clipping reduces the risk of intra-operative rupture of aneurysm and permits a better dissection of the sac with an adequate positioning of the definitive clip. In cases of small aneurysm with an easily accessible neck (that predict a temporary occlusion of the local arterial circulation) we consider the maintenance of optimal blood pressure very important. However we do not consider it essential to use electrophysiologic monitoring or other particular techniques of neuroprotection (which are vital in the surgery of giant or complex aneurysms).

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