gms | German Medical Science

Objective: Preoperative angiography is an inevitable step prior to microsurgical clipping of intracranial aneurysms to evaluate aneurysm location, size and morphology as well as vascular geometry. We hypothesized that surgical planning using three-dimensional (3D) reconstructed angiographic images would lead to a better spatial understanding of the aneurysm morphology, which might be associated with an improved surgical outcome in patients that receive microsurgical clipping of intracranial aneurysms.

Methods: Consecutive patients with subarachnoid haemorrhage that underwent microsurgical clipping at our institution between 2010 and 2017 were retrospectively reviewed. Surgical planning was made based on either two-dimensional (2D: computed tomography angiography and/or digital subtraction angiography) or 3D reconstructed angiographic images. Surgical details, procedural complications (intraoperative rupture and cerebral infarction) and angiographic results were obtained from the patient reports and compared between the groups by means of univariate and multivariate analysis.

Results: A total of 157 patients (mean age: 54.8±13.1) were enrolled into this study. Preoperative 3D angiographic imaging was available for 117 cases (74.5%). The interval between admission and surgery was significantly shorter in the 2D group (444±555 min) than in the 3D group (750±489 min, p<0.01). There were no significant differences in the operation time (p=0.1), the number of applied aneurysm clips (p=0.8), the number of clip replacements (p=0.9) and the number of times temporary clipping was performed (p=0.8). There was no significant difference in the intraoperative rupture rate between the 2D group (27%) and the 3D group (24%, p=0.7). However, procedure-related cerebral infarction occurred significantly more often in the 2D group (33%) than in the 3D group (16%, p=0.01). In the multivariate analysis, 2D imaging alone remained as an independent prognostic factor for subsequent cerebral infarction (odds ratio: 2.8, 95% confidence interval: 1.2–6.6; p=0.02). Favourable outcome (modified Rankin scale >2) was more often attained in the 3D group (70%) than in the 2D group (42%; p<0.01). The rate of complete aneurysm occlusion was not significantly different between both groups (p=1.0).

Conclusion: Careful operation planning using 3D angiographic reconstructions may reduce the rate of cerebral infarction after clipping of ruptured aneurysms and may improve patient outcome.