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(searched for: doi:10.3171/jns.1961.18.1.0098)
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, Nícollas Nunes Rabelo, João Paulo M. Telles, Leonardo Zumerkorn Pipek, Guilherme Bitencourt Barbosa, Natália Camargo Barbato, Antônio Carlos Samaia da Silva Coelho, Manoel Jacobsen Teixeira, Eberval Gadelha Figueiredo
Journal of Clinical Neuroscience, Volume 99, pp 78-81; https://doi.org/10.1016/j.jocn.2022.02.039

The publisher has not yet granted permission to display this abstract.
Kan Ma, John F. Bebawy
Anesthesia & Analgesia, Volume 135, pp 79-90; https://doi.org/10.1213/ane.0000000000005806

Abstract:
Burst-suppression is an electroencephalographic pattern that results from a diverse array of pathophysiological causes and/or metabolic neuronal suppression secondary to the administration of anesthetic medications. The purpose of this review is to provide an overview of the physiological mechanisms that underlie the burst-suppression pattern and to present in a comprehensive way the available evidence both supporting and in opposition to the clinical use of this electroencephalographic pattern as a therapeutic measure in various perioperative settings.
, Debabrata Sahana, Girish Menon
Asian Journal of Neurosurgery, Volume 16, pp 237-242; https://doi.org/10.4103/ajns.ajns_465_20

Abstract:
Temporary clips are invaluable safety tools during the clipping of an aneurysm. Controversies regarding maximum permissible duration and safety, however, remain unanswered. This descriptive narrative attempts to review the literature to provide valuable insights on controversies clouding the use of temporary clips among neurosurgeons. Popular databases, including Pub Med, Medline/Medscape, Scopus, Cochrane, Embase, Google Scholar, were searched to find available literature on temporary clips. The searched MeSH terms were “Temporary Clip,” “Temporary Clipping,” “Cerebral Aneurysm,” and “Aneurysm.” Temporary clips have been in use since 1928 and have undergone considerable structural and technical modifications. A temporary clip's optimal safety limit is not yet defined with literature evidence ranging from immediate to 93 min. It is not yet definite whether temporary clips application aggravates vasospasm, but emergency temporary clips application, especially in poor-grade aneurysmal subarachnoid hemorrhage patients, is associated with poor outcomes. A temporary clip needs to be applied with caution in patients treated earlier by endovascular technique and having indwelling stents. Nitinol Stent is feasible, while a Cobalt-Chromium alloy stent does not get occluded and gets deformed under the closing pressure of a temporary clip. Although a temporary clip application is a fundamental strategy during the clipping of an aneurysm; the exact safe duration remains to be decided in randomized control trials. Their utility for the shorter duration is beneficial under un-conclusive evidence of neuroprotective agents and intraoperative monitoring. Neurosurgeons need to consider all aspects of their pros and cons for optimal use.
, Antonio Nogueira Almeida, Apio Claudio Martins Antunes
Published: 7 May 2014
The publisher has not yet granted permission to display this abstract.
, Sudhir S. Pal, Sunil K. Gupta, Sandeep Mohindra, Rajesh Chhabra, Surender K. Malhotra
Published: 8 December 2012
Acta Neurochirurgica, Volume 155, pp 237-246; https://doi.org/10.1007/s00701-012-1571-2

Abstract:
Elective temporary clipping (ETC) is increasingly used in surgery for aneurysms. This study was to assess whether the impact of ETC on intraoperative aneurysmal rupture (IAR) translates into neurological outcome. Patients who underwent surgery for ruptured anterior circulation aneurysms were prospectively studied for various factors related to ETC, IAR and neurological outcome at 3 months. Univariate and multivariate analyses were performed using SPSS20. Of the total 273 ruptured aneurysm surgeries studied, IAR was observed in only six out of 132 aneurysms (4.5 %) who had ETC, compared with 78 out of 141 (55.3 %) without ETC (p< 0.001). Aneurysms complicated by IAR had significantly longer clipping time (8.3 min) compared with those without IAR (1.9 min) (p< 0.001). IAR had significant association with unfavorable outcome (38 % vs. 24 %) (p = 0.02). Patients with ETC had significantly shorter clipping time (2.9 min) compared with those without ETC (4.8 min) (p = 0.02). Unfavorable outcome was noted in 30 out of 132 with ETC (23 %), compared with 48 out of 141 without ETC (34 %) (p = 0.04). This beneficial effect was nonsignificantly greater in younger and good clinical grade patients. While episodes of ETC within clipping time of 20 min did not show significant difference in outcome, repeated rescue clipping (45 % unfavorable outcome, p = 0.048) and total clipping time of at least 20 min (75 % unfavorable outcome, p = 0.008) had significant impact on outcome. In multivariate analysis, the use of ETC (p = 0.027) and total temporary clipping less than 20 min (p = 0.049) were noted to result in significantly better outcome, independent of other factors. The use of ETC decreased the occurrence of IAR and the total clipping time, thereby leading to significantly better outcome, independent of other factors. While repeated elective clipping within total clipping time of 20 min did not influence outcome, repeated rescue clipping and total clipping time of at least 20 min had significant impact on outcome.
Published: 30 June 2012
Neurochirurgie, Volume 58, pp 76-80; https://doi.org/10.1016/j.neuchi.2012.02.022

Abstract:
Many important issues regarding the management of intracranial aneurysms remain controversial. We review the role played by randomized trials in the determination of the best management of intracranial aneurysms in the early era of surgical clipping. Landmark trials and cooperative studies are analyzed and results summarized in a narrative review. The most convincing evidence in favour of surgical management of ruptured intracranial aneurysms came from early randomized trials conducted from the 1950s to 1970s. Large historical observational studies, performed between the 1970s and 2000, aiming to guide clinical practice, provided only statistical associations mixed with confounding variables. After the early RCTs, the next important gain in reliable knowledge occurred with completion of the ISAT trial, more than 25 years later. The pioneering neurosurgeons of early trials can provide the inspiration necessary to make real progress in understanding the best clinical management of intracranial aneurysms.
Behzad Eftekhar,
Journal of Clinical Neuroscience, Volume 18, pp 905-909; https://doi.org/10.1016/j.jocn.2010.12.009

Abstract:
This study was undertaken to determine variables that could predict, in the preoperative period, the likelihood for the need for intraoperative temporary arterial occlusion using clips (temporary clipping) when surgically repairing intracranial aneurysms. Data collected prospectively between October 1989 and March 2010 of 1129 unruptured intracranial aneurysms in 934 patients who were managed surgically was examined retrospectively. Temporary clipping was used in 400 patients (35.4%). Regression analysis of putative predictive variables revealed that aneurysms of a larger size, irregular fundus shape or midline location were more likely to be treated with temporary clipping. Basilar caput aneurysms larger than 10mm were always managed with temporary clipping. There was no combination of factors studied that consistently predicted that temporary clipping would not be needed. Therefore, the potential need for temporary clipping must be considered for every patient with an aneurysm.
, Ahmet Celal Iplikcioglu, Nurgul Aytan, Deniz Ozcan, Tangul San, Nesrin Kartal-Özer, Ali Fahir Ozer
Published: 31 May 2008
Surgical Neurology, Volume 69, pp 483-488; https://doi.org/10.1016/j.surneu.2007.01.053

Abstract:
We compared the effect of temporary aneurysm clips on atherosclerotic and nonatherosclerotic CCA of rabbits by morphometric and ultrastructural methods. The rabbits (N = 12) were divided into 2 groups: the first group was fed a 2% cholesterol diet, and the second group, a normal diet for 4 weeks. Atherosclerotic lesions developed after 4 weeks. Temporary aneurysm clips were placed on the left CCA of both groups; the right CCA of both groups served as control. Thus, a total of 4 groups were used: atherosclerotic (A), atherosclerotic/clip (AC), nonatherosclerotic (NA), and nonatherosclerotic/clip (NAC). Temporary aneurysm clips were applied for 1, 5, and 10 minutes in the AC and NAC groups. No temporary clip was placed on the right CCA (A and NA groups). The affected parts of the CCA via clips were examined under light microscope and SEM. Comparison of atherosclerotic and nonatherosclerotic CCA of rabbits under light microscope indicated that the wall of atherosclerotic CCA was thicker than that of nonatherosclerotic CCA. The difference between the thickness of atherosclerotic and nonatherosclerotic CCAs was significant. SEM analyses showed that in nonatherosclerotic CCAs, the effect of temporary aneurysm clips was seen after 10 minutes, but in atherosclerotic CCAs, the effect was seen within the 1st minute of clipping and continued in the 5th and 10th minutes. The duration of temporary clipping should be decreased for the neurovascular surgery of atherosclerotic patients.
Paulo Henrique Aguiar, Antonio Noguiera Almeida
Published: 19 October 2007
The publisher has not yet granted permission to display this abstract.
Iman Feiz-Erfan, Patrick P. Han, Robert F. Spetzler, Eric M. Horn, Jeffrey D. Klopfenstein, Louis J. Kim, Randall W. Porter, Stephen P. Beals, Salvatore C. Lettieri, Edward F. Joganic
Operative Neurosurgery, Volume 57, pp 86-93; https://doi.org/10.1227/01.neu.0000163487.94463.4a

Abstract:
OBJECTIVE: Olfaction is often sacrificed to gain access to the cranial base in anterior craniofacial surgery. We describe the long-term results of olfactory function in patients who underwent anterior craniofacial surgery and a cribriform plate osteotomy to preserve olfaction.METHODS: Between 1992 and 2004, 28 patients underwent 29 cribriform plate osteotomies in an attempt to preserve olfaction during anterior craniofacial surgery performed through modified extended transbasal approaches. Patients' charts and office notes were reviewed retrospectively. Formal olfactory testing was available in 5 patients, but most data were based on patients' subjective reports of olfaction. Olfactory preservation was defined by the subjective ability to detect fumes such as coffee, chocolate, roses, and orange juice regardless of the intensity of the sensation. Follow-up was based on phone calls to patients.RESULTS: Four patients were lost to follow-up and excluded. Therefore, follow-up was available in 24 patients after 25 procedures. On the basis of patients' subjective reports, olfaction was spared in 22 patients after 23 procedures (92%) and was confirmed objectively in the five patients formally tested. After surgery, only two patients were anosmic.CONCLUSION: Olfaction can be preserved in selected patients undergoing anterior craniofacial surgery. At least 1 cm of nasal mucosa should remain attached to the cribriform plate, which can be achieved by including the nasal bone in the osteotomy of the orbital bar. A medial orbital canthopexy is therefore necessary after these procedures.
M. Medina, A. Lucano, N. Serio, V. Meus, A. Lippiello, L. Gozzoli
Published: 1 October 2002
Rivista di Neuroradiologia, Volume 15, pp 583-587; https://doi.org/10.1177/197140090201500514

Abstract:
Temporary clipping is very useful in the treatment of cerebral aneurysms since it permits a better approach and manipulation of the sac by reducing blood pressure on the aneurysmal wall. This procedure in not free of risks such as possible damage to the arterial wall and distal ischaemia. We evaluated retrospectively 107 cases treated between 1998 and 2001 in our unit and compared our results with literature reports.
Richard Ferch, Alberto Pasqualin, Giampietro Pinna, Franco Chioffi, Albino Bricolo
Journal of Neurosurgery, Volume 97, pp 836-842; https://doi.org/10.3171/jns.2002.97.4.0836

Abstract:
Object. This study was performed to further elucidate technical and patient-specific risk factors for perioperative stroke in patients undergoing temporary arterial occlusion during the surgical repair of their aneurysms. Methods. One hundred twelve consecutive patients in whom temporary arterial occlusion was performed during surgical repair of an aneurysm were retrospectively analyzed. Confounding factors (inadvertent permanent vessel occlusion and retraction injury) were identified in six cases (5%) and these were excluded from further analysis. The demographics for the remaining 106 patients were analyzed with respect to age, neurological status, aneurysm characteristics, intraoperative rupture, duration of temporary occlusion, and number of occlusive episodes; end points considered were outcome at 3-month follow up and symptomatic and radiological stroke. Conclusions. Overall 17% of patients experienced symptomatic stroke and 26% had radiological evidence of stroke attributable to temporary arterial occlusion. A longer duration of clip placement, older patient age, a poor clinical grade (Hunt and Hess Grades IV–V), early surgery, and the use of single prolonged clip placement rather than repeated shorter episodes were associated with a higher risk of stroke based on univariate analysis. Intraoperative aneurysm rupture did not affect stroke risk. On multivariate analysis, only poorer clinical grade (p = 0.001) and increasing age (p = 0.04) were significantly associated with symptomatic stroke risk.
Paulo H. Aguiar, Guilherme A. Pulici, Leonardo O. Lourenco, Juan A.C. Flores, Valter A. Cescato
Published: 1 March 2002
by SciELO
Arquivos de Neuro-Psiquiatria, Volume 60, pp 12-16; https://doi.org/10.1590/s0004-282x2002000100003

Abstract:
The bifrontal craniotomy approach used to be associated with a high percentage of olfactory tract damage. We present our experience with this technique, that was used with excellent results in a series of 11 patients that underwent the surgical approach described in this paper. We support the idea that bilateral subfrontal craniotomy allows a wide operative exposure as well as the complete anatomic and functional preservation of the olfactory tracts bilaterally.
H. Hunt Batjer, R. Tyler Frizzell, Thomas A. Kopitnik, Duke S. Samson
Published: 1 January 2001
Loss, Grief & Care, Volume 9, pp 5-22; https://doi.org/10.1300/j132v09n01_02

Luiz Antonio Araujo Dias, Benedicto Oscar Colli, Joaquim Coutinho Netto,
Published: 1 December 2000
by SciELO
Arquivos de Neuro-Psiquiatria, Volume 58, pp 1047-1054; https://doi.org/10.1590/s0004-282x2000000600012

Abstract:
A isquemia cerebral é fenômeno eventualmente observado durante procedimentos neurocirúrgicos e em patologias clínicas resultando em déficits neurológicos incapacitantes ou mesmo na morte. Por tratar-se de problema grave e de difícil solução, vários estudos têm sido efetuados com o objetivo de elucidar os mecanismos do fenômeno isquêmico no sistema nervoso central (SNC) e abolir ou diminuir seus efeitos através das drogas que protegem os neurônios (neuroprotetoras). Vários neurotransmissores estão envolvidos na isquemia e entre eles o glutamato destaca-se pela sua maior concentração no SNC. O objetivo deste estudo foi avaliar a isquemia cerebral focal em ratos através da dosagem do glutamato e dos achados morfológicos em uma evolução temporal e demonstrar uma possível ação neuroprotetora do cetoprofeno. Foram utilizados 36 ratos Wistar, subdivididos em 4 grupos: um grupo controle e outro sham; e outros dois em que os animais foram submetidos a isquemia pela oclusão seletiva da artéria cerebral média por um fio obstrutor durante 15, 30 e 45 minutos. Os animais de um destes grupos foram tratados com cetoprofeno 15 minutos antes da isquemia. A isquemia foi avaliada através de estudo histopatológico e da dosagem do glutamato extracelular in vitro. A análise morfológica mostrou não haver diferenças entre os animais normais e do grupo sham. Nos animais submetidos a isquemia, as alterações apareceram aos 30 minutos e acentuaram-se aos 45. Os principais achados foram edema intersticial, desorganização cromatínica, vacuolização e desintegração nuclear. Os animais tratados com cetoprofeno apresentaram alterações semelhantes, porém menos intensas. Reduções nas dosagens in vitro do glutamato extracelular no córtex parietal dos animais submetidos a isquemia iniciaram-se a partir dos 30 minutos e acentuaram-se aos 45 e foram semelhantes nos animais com ou sem tratamento com cetoprofeno, indicando que esta droga parece não interferir com o metabolismo do glutamato na sinapse. Os achados histopatológicos no córtex parietal dos animais submetidos a isquemia , tratados ou não previamente com cetoprofeno, sugerem que esta droga tem um efeito neuroprotetor.
Iver A. Langmoen, K. Ekseth, E. Hauglie-Hanssen, H. Nornes
Published: 1 January 1999
The publisher has not yet granted permission to display this abstract.
Christopher L. Taylor, Warren R. Selman
Neurosurgery Clinics of North America, Volume 9, pp 673-679; https://doi.org/10.1016/s1042-3680(18)30221-3

The publisher has not yet granted permission to display this abstract.
James P. Chandler, Christopher C. Getch, H. Hunt Batjer
Neurosurgery Clinics of North America, Volume 9, pp 861-868; https://doi.org/10.1016/s1042-3680(18)30234-1

The publisher has not yet granted permission to display this abstract.
E. Sander Connolly,
Neurosurgery Clinics of North America, Volume 9, pp 681-696; https://doi.org/10.1016/s1042-3680(18)30222-5

Abstract:
Surgical management of giant cerebral aneurysms remains a major technical challenge for modern neurosurgeons. Endovascular approaches for giant aneurysms does not provide an acceptable alternative to direct surgical approaches. The use of deep hypothermic circulatory arrest as an adjunct during clipping of complex giant aneurysms shows promise as a treatment for otherwise incurable lesions. Patient selection and techniques of circulatory arrest surgery are discussed.
NeuroReport, Volume 9, pp 321-325; https://doi.org/10.1097/00001756-199801260-00026

Abstract:
To investigate whether sublethal ischemia preserves neuronal function otherwise lost after stroke, anesthesized rabbits were subjected to clamping of abdominal aorta to cause lumbar spinal cord ischemia. An occlusion period of 12.5 min was followed 12 or 48 h later by a second occlusion for 30 min. When scored 24 h later for hindlimb function on a 0-6 scale, the rabbits that underwent tolerizing ischemia 12 h before infarction had better motor function (n = 7; 4.29+/-0.21,p < 0.0001) than sham-operated controls (n = 7; 1.00+/-0.27), but those infarcted at 48 h had mixed outcomes (n = 5; 2.20+/-0.21, ns). In correlation, the proportion of neurons with histological evidence of damage was lower in the tolerized rabbits (0.15+/-0.04) than in sham-operated controls (0.74+/-0.09, p < 0.001). We conclude that ischemic tolerance also improves neurological function of infarcted spinal cord and could be studied for clinical application.
Sean D. LaVine, Lena S. Masri, Michael L. Levy, Steven L. Giannotta
Journal of Neurosurgery, Volume 87, pp 817-824; https://doi.org/10.3171/jns.1997.87.6.0817

Abstract:
✓ The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of potential brain-protection anesthetics, a group of patients treated with the intravenous agents propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane. Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous brain-protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP anesthesia, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the group that did not receive brain protection (NBP). In the NBP group, the mean duration of temporary occlusion was 3.9 ± 2.2 minutes for patients without infarction versus 12.2 ± 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 ± 10.6 minutes for patients without infarction and 18.5 ± 9.9 minutes for patients with infarction in the IVBP group. All patients (four of four) in the NBP group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group (p < 0.0001). Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at decreased risk. It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving isoflurane when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and its use in patients with multiple aneurysms need further evaluation before specific recommendations can be made.
, R. T. W. M. Thomeer
Published: 1 April 1997
Acta Neurochirurgica, Volume 139, pp 355-358; https://doi.org/10.1007/bf01808833

The publisher has not yet granted permission to display this abstract.
Christopher L. Taylor, Warren R. Selman, Steven P. Kiefer, Robert A. Ratcheson
Published: 1 November 1996
Neurosurgery, Volume 39, pp 893-906; https://doi.org/10.1227/00006123-199611000-00001

Carlos A. David, Ricardo Prado,
Journal of Neurosurgery, Volume 85, pp 923-928; https://doi.org/10.3171/jns.1996.85.5.0923

Abstract:
✓ Temporary arterial occlusion has been routinely used as an adjunct in intracranial aneurysm surgery. This has commonly been performed using a protocol of multiple short periods of occlusion alternating with periods of restoration of normal circulation. Recently, the logical basis of this method has come under scrutiny. There is extensive experimental evidence to suggest that repetitive, brief periods of global ischemia may cause more severe cerebral injury than an equivalent single period of global ischemia. Only recently has this issue begun to be addressed with regard to focal ischemia. Hence, despite the common use of temporary clipping, little experimental data are available regarding the ischemic consequences of temporary arterial occlusion with periods of reperfusion versus uninterrupted temporary occlusion. To investigate this issue, a protocol of occlusion/reperfusion that simulates the temporal profile that occurs during surgery was performed in a rat model of focal ischemia. Sixteen anesthetized Sprague—Dawley rats were divided into two groups. The animals in Group I underwent 60 minutes of uninterrupted middle cerebral artery occlusion and the animals in Group II were subjected to six separate 10-minute occlusion periods with 5 minutes of reperfusion between occlusions. Histopathological analysis was performed 72 hours postischemia. Group I had significantly increased mean infarction volumes (50.0 ± 12.1 mm3) compared to Group II (8.7 ± 3.1 mm3) (p = 0.008). Injuries in Group I occurred in both the cortex and striatum, whereas Group II showed only striatal injuries. Furthermore, the extent of the injuries in Group II was less severe, characterized by ischemic neuronal injury rather than frank infarction. The results indicate that intermittent reperfusion is neuroprotective during temporary focal ischemia and support the hypothesis that intermittent reperfusion is beneficial if temporary clipping is required during aneurysm repair.
, Warren R. Selman, Steven P. Kiefer, Robert A. Ratcheson
Neurosurgery, Volume 39, pp 893-906; https://doi.org/10.1097/00006123-199611000-00001

Abstract:
Any method that decreases the risk of intraoperative rupture should improve outcome if complications associated with its use do not negate positive effect. If application time is limited and a form of cerebral protection and appropriate monitoring of cerebral function are used, temporary clip application may meet these requirements. The efficacy of temporary occlusion as an adjunct to aneurysm clipping may be limited by technical considerations with respect to regional anatomy, aneurysm size, and aneurysm consistency. In areas of limited access, positioning proximal clips may not be feasible. The use of endovascular techniques of balloon occlusion may provide proximal control in these situations (9, 106). The decision to use total circulatory arrest and profound hypothermia, as opposed to temporary clip application, remains largely a matter of the surgeon's judgment. The role of proximal parent vessel ligation must also be considered in the decision-making process regarding the treatment of giant or technically difficult aneurysms (114). Further refinements in cerebral monitoring that can accurately reflect intracellular processes in all territories affected by the application of temporary clips or balloon occlusion and development of more effective forms of cerebral protection may permit safer use of this technique. An adequately controlled clinical trial of temporary occlusion with or without putative "cerebral protection" is needed to confirm the efficacy of this technique.
Christopher S. Ogilvy, Bob S. Carter, Stuart Kaplan, Charles Rich, Robert M. Crowell
Journal of Neurosurgery, Volume 84, pp 785-791; https://doi.org/10.3171/jns.1996.84.5.0785

Abstract:
✓ Temporary vessel occlusion is an effective technique used by microvascular surgeons to facilitate dissection and permanent clipping of cerebral aneurysms; however, several questions remain regarding the overall safety of this technique. To identify technical and patient-specific risk factors for perioperative stroke, the authors examined a series of patients in whom induced hypertension and mild hypothermia and intravenous mannitol administration were used as protection during temporary vessel occlusion for aneurysm clipping. The study comprises a nonconcurrent prospective analysis of 132 consecutive aneurysm clippings performed with the aid of temporary vascular occlusion and a specific antiischemic anesthetic protocol at the Massachusetts General Hospital from 1991 to 1993. Factors studied included duration of the temporary clip application, number of occlusive episodes, patient age and neurological status, presence of preoperative subarachnoid hemorrhage (SAH), and intraoperative aneurysm rupture (“forced” temporary clipping), as well as whether proximal vessel occlusion or complete aneurysm trapping was used. In a univariate analysis, patient age, intraoperative aneurysm rupture, temporary clipping lasting more than 20 minutes, clipping between the 4th and 10th day after SAH, and multiple clipping episodes were all significantly associated with stroke outcome. Multivariate logistic regression revealed that intraoperative aneurysm rupture (relative risk 5.6, p = 0.02) and a duration of temporary clip application that lasted more than 20 minutes (relative risk 9.4, p = 0.04) were independently associated with stroke outcome. Overall, 5.2% of the patients had postoperative clinical strokes. Based on their findings the authors conclude that temporary clipping is a safe adjunct to aneurysm surgery, particularly when the duration of clipping is short.
Hiroshi Karibe, Gregory J. Zarow, Philip R. Weinstein
Journal of Neurosurgery, Volume 83, pp 93-98; https://doi.org/10.3171/jns.1995.83.1.0093

Abstract:
✓ To determine which of two treatments for reducing ischemic injury after temporal focal ischemia is more effective, the effects of mild (33°C) intraischemic hypothermia were compared with those of mannitol, the most commonly used neuroprotective agent. Four groups of Sprague-Dawley rats underwent 1 hour of endovascular middle cerebral artery occlusion followed by 23 hours of normothermic reperfusion. The four experimental groups were as follows: Group A, saline control; Group B, mannitol (25%, 1 g/kg); Group C, hypothermia; and Group D, hypothermia plus man-nitol. Laser-Doppler estimates of cortical blood flow showed that hypothermia did not affect blood flow during ischemia or reperfusion. Mannitol increased cortical blood flow during ischemia and reperfusion under both normothermic and hypothermic conditions (p < 0.05). Neurological deficit was significantly less severe in treated rats (Group B, p < 0.05; Group C or D, p < 0.01) than in controls (Group A). Infarct volume, measured on semiserial Nissl-stained sections, was significantly smaller in treated rats (p < 0.01) than in controls. Infarct volume was also significantly smaller in rats treated with hypothermia than in those treated with mannitol (Group C vs. Group B, p < 0.05); there was no difference between rats treated with mannitol and those treated with mannitol and hypothermia. All three treatments reduced infarct area in the ischemic penumbra; hypothermia with or without mannitol also reduced infarct area in the ischemic core. These results demonstrate that both mild intraischemic hypothermia and mannitol reduce infarct size and neurological deficit: hypothermia reduces infarct size more effectively than mannitol, and mannitol adds no significant protection to hypothermia, whereas hypothermia adds significant protection beyond that afforded by mannitol after brief focal ischemia followed by reperfusion in rats. The results suggest that mild intraischemic hypothermia alone, or in combination with mannitol, may be useful in avoiding ischemic injury from temporary vessel occlusion during cerebrovascular surgery.
L. Rabow, G. Algers, J. Elfversson, O. Rudolphi, S. Zygmunt
Published: 1 March 1995
Acta Neurochirurgica, Volume 133, pp 13-16; https://doi.org/10.1007/bf01404941

The publisher has not yet granted permission to display this abstract.
E. C. G. Ventureyra, M. J. Higgins
Published: 1 August 1994
Child's Nervous System, Volume 10, pp 361-379; https://doi.org/10.1007/bf00335125

The publisher has not yet granted permission to display this abstract.
H. Hunt Batjer, D. S. Samson
Published: 1 January 1994
The publisher has not yet granted permission to display this abstract.
Lindsay Symon
Published: 1 January 1994
The publisher has not yet granted permission to display this abstract.
Duke Samson, H. Hunt Batjer, Bowman Gary, Lee Mootz, William J. Krippner, Yves J. Meyer, Beth C. Allen
Neurosurgery, Volume 34, pp 22-29; https://doi.org/10.1097/00006123-199401000-00005

Abstract:
TEMPORARY OCCLUSION OF intracranial arteries has emerged as a valuable technical adjunct in the management of intracranial aneurysms. The current study considered 121 patients (from a group of 234 consecutive aneurysm patients treated during a 2-yr period) who underwent elective temporary arterial occlusion. Twenty-one patients were excluded from further study because of an intraoperative rupture of an aneurysm, the elective sacrifice of afferent or efferent vessels, or the performance of an extracranial-intracranial arterial bypass graft; the remaining 100 patients underwent elective temporary occlusion under a standard neuroanesthetic regimen, including etomidate-induced burst suppression, normotension, normovolemia, and normothermia. In the postoperative period, radiographic evidence of ischemic brain injury in the distribution of the arteries occluded was selected as the end point for the failure of occlusion tolerance. The parameters evaluated with respect to this end point included the duration and nature of the temporary arterial occlusion, the number of the occlusive episodes, the specific vascular territory occluded, patient age, neurological status, presence of subarachnoid hemorrhage, vasospasm, and aneurysm size Several parameters were found to be related to the postoperative development of ischemic injury. Patients more than 61 years of age and those in poor neurological condition (Hunt and Hess Grades III to IV) did not tolerate temporary occlusion as well as patients who were younger and in better condition. Patients occluded for less than 14 minutes routinely tolerated the iatrogenic ischemia; the 95% confidence level for the toleration of occlusion without the development of infarction occurred at 19 minutes. All patients occluded for more than 31 minutes had both clinical and radiographic evidence of cerebral infarction. In patients undergoing periods of occlusion greater than 14 minutes the use of incomplete occlusion appeared to be associated with the development of cerebral infarction. Relative, although not statistically significant, associations with poor tolerance of temporary occlusion were found with increasing episodes of temporary occlusion and occlusion of perforator-bearing segments of middle cerebral or basilar arteries.
K. Kikuchi, K. Watanabe
Published: 1 March 1993
Acta Neurochirurgica, Volume 125, pp 127-131; https://doi.org/10.1007/bf01401839

Abstract:
A modified microsurgical bifrontal interhemispheric approach (small trephine craniotomy) for clipping of aneurysms of the anterior communicating artery (ACoA) is described. This approach has been used in a series of 23 patients with ACoA and 2 patients with distal anterior cerebral artery aneurysms. Feasibility, indications and problems related to this approach to ACoA aneurysms are assessed.
N. Yasui, , H. Fujiwara, A. Suzuki
Published: 1 September 1992
Acta Neurochirurgica, Volume 118, pp 91-97; https://doi.org/10.1007/bf01401292

The publisher has not yet granted permission to display this abstract.
L. Symon
Published: 1 June 1992
Acta Neurochirurgica, Volume 116, pp 107-118; https://doi.org/10.1007/bf01540863

The publisher has not yet granted permission to display this abstract.
, Nobuyuki Yasui, Takeshi Sampei, Akifumi Suzuki
Journal of Neurosurgery, Volume 76, pp 629-634; https://doi.org/10.3171/jns.1992.76.4.0629

Abstract:
✓ The intraoperative anatomical findings of the anterior communicating artery (ACoA) complex in 46 patients with anatomical variations were compared to those in an equal number of patients without variations in order to determine the visualization of the elements of the vascular complex. All patients underwent radical surgery for an ACoA aneurysm by one of three different surgical approaches: transsylvian, anterior interhemispheric, or basal interhemispheric. Visualization of the vascular elements was similar in patients with or without anatomical variations. The differences observed were dependent on the surgical approach selected and on the projection of the aneurysm. It was found that, even when the intraoperative anatomical field and the number of vascular elements visualized are different from those obtained in autopsy studies, the vascular microanatomical characteristics can be confirmed with each surgical approach to the extent necessary to ensure safe clipping of aneurysms in patients both with and without anatomical variations.
I. H. Aydin, , I. Tahmazoglu, G. R. Kayaoglu
Published: 1 March 1992
Acta Neurochirurgica, Volume 119, pp 101-103; https://doi.org/10.1007/bf01541791

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Fady T. Charbel, James I. Ausman, Fernando G. Diaz, Ghaus M. Malik, Manuel Dujovny, James Sanders
Published: 31 August 1991
Surgical Neurology, Volume 36, pp 83-90; https://doi.org/10.1016/0090-3019(91)90223-v

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T. Fukushima, Sh. Miyazaki, Y. Takusagawa, M. Reichman
Published: 1 January 1991
Abstract:
A special midline interhemispheric keyhole approach to the anterior communicating artery aneurysms is described. A small trephine opening of 3 cm in diameter is used in most cases. The detailed microsurgical technique of the unilateral interhemispheric exposure of the anterior cerebral artery complex is presented. For the past 10 years, a total of 138 patients, 112 with Acom AN and 26 with distal ACA AN, were operated upon through this approach. There were 16 cases with non-ruptured aneurysms and the postoperative results were excellent in all of them. The overall results in 122 cases with ruptured aneurysms were excellent and good (working) in 95 cases, fair in 10 cases, poor in 9 and death supervened in 8 cases. The mortality rate in 71 acute operation cases was 8% and 4% in 51 delayed cases. The advantages of this approach include simple and rapid craniotomy, minimum brain retraction, accurate midline exposure of all parent arteries and the aneurysm. This anterior interhemispheric approach is, in our experience, much superior to the conventional pterional approach.
Kjeld Dons Eriksen, Torben Bøge-Rasmussen, Christian Kruse-Larsen
Journal of Neurosurgery, Volume 72, pp 864-865; https://doi.org/10.3171/jns.1990.72.6.0864

Abstract:
✓ Damage to the olfactory nerve during frontotemporal approach to the basal cisternal region has not previously been investigated in a quantified manner. In this retrospective study of 25 patients operated on for ruptured intracranial aneurysms via the frontotemporal route, 22 patients suffered postoperatively from anosmia ipsilateral to the side of surgery. This complication most often goes unrecognized by the patient as well as the physician, and attention should be drawn to it because of its widespread occurrence. This investigation demonstrates a high incidence of anosmia (24 (88.9%) of 27 surgical sides) occurring ipsilateral to the frontotemporal approach in aneurysm surgery. Recovery after traumatic anosmia has been recorded up to 5 years after injury.1 Nevertheless, the authors believe that the damage is permanent when lasting 35 months or longer.
Bengt Ljunggren, John L. Fox
Published: 1 January 1989
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A. Buchthal, M. Belopavlovic, J. J. A. Mooij
Published: 1 March 1988
Acta Neurochirurgica, Volume 93, pp 28-36; https://doi.org/10.1007/bf01409899

Abstract:
Temporary occlusion of the parent artery greatly facilitates the dissection of large cerebral aneurysms, while much reducing the risk of intraoperative rupture and avoiding the use of profound arterial hypotension. Intraoperative somatosensory evoked potential (SEP) monitoring was carried out in 25 aneurysm cases where temporary clipping was employed electively under moderate hypothermia. Occlusion times ranged from 6.3 to 52 minutes at 28.7 ‡C to 32.5 ‡C.
Anthony Jabre, Symon Lindsay
Published: 31 January 1987
Surgical Neurology, Volume 27, pp 47-62; https://doi.org/10.1016/0090-3019(87)90107-8

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