gms | German Medical Science

Objective: The treatment of acute subarachnoid haemorrhage includes patient transfer for diagnostic and therapeutic facilities. This may be especially cumbersome in critically unstable patients. Thus, we aimed for the development of a combined imaging, endovascular and surgical suite, which allows for diagnostic imaging as well as intraoperative imaging (CT and 3-D rotational angiography).

Methods: We combined recent Flat-Panel technology (Philips Allura Xper FD 20) with a sterile surgical and neurointerventional environment. It allows for intraoperative high-speed image acquisition (up to 620 projections along 240° in 8–10 sec, rotational speed: 30°/55°/s, 30 frames/sec) and automated segmentation of vascular structures. N=42 patients harbouring 57 aneurysms underwent treatment within this setup (n=30 clipping, n=9 endovascular, n=3 combined endovascular/surgical), a total amount of n=63 intraoperative 3-D angiographies has been performed.

Results: Time from diagnosis to treatment was reduced in all acute cases as admission CT imaging with the flat-panel detector could be performed at the same location as subsequent endovascular and/or surgical treatment as well as angiographic control (n=42). External ventricular drain placement was performed immediately after admission XperCT (n=1). Neurosurgical or neurointerventional treatment or combined approaches were performed on acute and elective cases, e.g. clipping with proximal endovascular control or combined embolisation/clipping (n=30 clipping, n=9 coiling, n=3 combined). Intraoperative 3-D-rotational angiography was performed in n=42 patients <15 min. It allowed for direct control of aneurysm clipping with an open situs and ruled out incomplete clipping (n=6), vascular compromise (n=1) or insufficiently coiled neck remnants (n=2). Direct repositioning of aneurysm clips (n=9) was performed in n=6 patients. Finally, intraoperative 3-D angiography led in 18,8 % to discovery of clip-related complications, to clip repositioning and thus, to reduction of revisions. A complete clip occlusion rate of 100% has been achieved after the first intervention.

Conclusions: A combined neurointerventional suite is of particular value for treatment of cerebral aneurysms. It improves the overall management of aneurysmal subarachnoid haemorrhage and aneurysms in terms of the (peri-) interventional workflow, and by preventing the necessity for extraoperative angiographic control with potential revision in a second operation.