Article
The use of intraoperative CT angiography during elective clipping of cerebral aneurysms improves complete aneurysm obliteration rates
Die Anwendung derintraoperativenCT-Angiographie während des elektiven Aneurysmaclippingsführt zu einer verbessertenVerschlussrate inder Aneurysmaversorgung
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Published: | June 26, 2020 |
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Objective: Complete aneurysm occlusion is mandatory to prevent recurrent aneurysm formation. Up to now, the goldstandard still is postoperative angiography (pDSA) to confirm complete aneurysm occlusion and to rule out perioperative complications such as vasospasm or clip stenosis. As recent technical progress enables to perform intraoperative CT angiography (iCTA) in the clinical routine, we analyzed whether this method can improve obliteration rates by early detection of aneurysm remnants.
Methods: All patients treated with primary aneurysm clipping between 11/2012 and 10/2019 at our center receiving pDSA were retrospectively analyzed. Surgery was performed by 6 specialized vascular neurosurgeons. iCTA was routinely performed since 10/2016. Clinical outcome was assessed postoperatively, at discharge and atfollow-up (last in 11/2019). iCTA and pDSA were analyzed by experienced neuroradiologists.
Results: A total of 293 patients were treated for aneurysm clipping within the mentioned time period. 45 patients without pDSA due to contraindications for pDSA (n=32), compliance (n=6), follow-up reasons (n=7) were excluded. Of the included 248 patients, 70 received iCTA and 178 did not. The two cohorts did not significantly differ in terms of age (54.6 vs. 57.3), sex (f/m: 56/14 vs.121/57), and aneurysm size (6.8 vs. 6.9mm). The frequencies of surgeons were similar in both groups (p=0.12). Aneurysm location was equally distributed on MCA (57.1 vs. 57.9%) > ACOM (14.3 vs. 20.2%)> ACI (14.3 vs.10.7%)> others (p=0.62). pDSA was described abnormal in 60 patients, judged as relevant in 22 cases, required revision in 3 cases, and judged as best achievable result for further observation in 35 cases. Patients who underwent elective clipping under iCTA guidance showed an abnormality on pDSA in 12.9% compared to 28.7% without iCTA guidance (p<0.009). In particular, an aneurysm remnant was described in 10.0 vs. 19.1% (p=0.08) of cases, resulting in surgical revisions in 1.4 vs. 1.1% (p=0.84). Clip stenosis was detected in 1.4 vs. 8.5% (p= 0.04) and vasospasm in 1.4 vs. 3.4% (p= 0.41). Clinical outcome did not significantly vary between groups: 95.7 vs. 93.3% (p=0.47) of patients had no permanent neurological deficit and average GOS at last follow-up was 4.9 vs. 4.9 (p=0.89).
Conclusion: The use of iCTA significantly improves complete obliteration rates insurgical aneurysm clipping.