Immediate Postoperative Angiography after Aneurysm Clipping - Implications for Quality Control and Guidance of Further Management

Abstract

Background: To determine the impact of postoperative angiography after aneurysm clipping on quality control and further management.
Methods: A recent consecutive series of n = 296 patients (186 females, 110 males, mean age 51 yrs) who underwent 324 craniotomies to clip 384 aneurysms was reviewed. New irregularities on postoperative angiographies were categorized as unrelated (e. g. vasospasm) or related (= vessel occlusion/residuum) to clipping and expected or unexpected by the surgeon. Therapies prompted by these findings as well as subsequent negative sequelae were analyzed. Factors related to negative events were identified by logistic regression (p < 0.05).
Results: Twenty-six (8 %) unrelated findings prompted medical or intravascular therapy. Of 36 (9.4 %) clip-related findings (n = 17 occlusions, n = 19 residua), 14 (3.6 %) were unexpected (n = 9 occlusions, n = 5 residua). This was followed by 9 (2.3 %, n = 4 occlusions, n = 5 residua) clip readjustments and 6 aggressive medical therapies. Nine patients were scheduled for angiographic follow-up, of which in five performed so far no change of aneurysm remnants was noted. Permanent sequelae from vessel occlusion occurred in 9 cases. Major premature rupture (p < 0.005), giant size/fusiform configuration (p < 0.001), posterior circulation aneurysms (p < 0.05) and ophthalmic segment location (p < 0.008) were significantly related to adverse postoperative findings. The use of microvascular Doppler significantly reduced the rate of unexpected vessel occlusion (3.3 vs. 0.9 %).
Conclusions: Apart from the need for quality control in aneurysm clipping - especially with respect to coiling - our results stress the importance of postoperative angiography, because a small, but significant subset of patients will benefit from immediate intervention and/or deserves long-term follow-up.

Zusammenfassung

Hintergrund: Die Auswirkungen der unmittelbar postoperativen Angiographie nach Aneurysmaclipping auf die Qualitätskontrolle und das weitere Management zu untersuchen.
Methoden: Eine neuere konsekutive Serie von n = 296 Patienten (W = 186, M = 110, Durchschnittsalter: 51 Jahre), bei denen 324 Kraniotomien zur Clipausschaltung von 384 Aneurysmen erfolgten, wurde retrospektiv untersucht. Neue Unregelmäßigkeiten in den postoperativen Angiographien wurden als clipunabhängig (z. B. Vasospasmen) oder clipabhängig (Gefäßverschluss/Aneurysmarest) und als erwartet oder unerwartet durch den Chirurgen kategorisiert. Nachfolgende Therapien und negative Ereignisse wurden analysiert und Faktoren im Zusammenhang mit diesen durch logistische Regression identifiziert (p < 0,05).
Ergebnisse: 26 (8 %) clipunabhängige Befunde waren Anlass für medikamentöse oder intraarterielle Therapien. Von insgesamt 36 clipabhängigen Befunden (n = 17 Verschlüsse, n = 19 Residuen), waren 14 (3,6 %) unerwartet (n = 9 Verschlüsse, n = 5 Residuen). Dies hatte 9 Clip-Repositionen (2,3 %, n = 4 Verschlüsse, n = 5 Residuen) und 6 aggressive medikamentöse Therapien zur Folge. Neun späte Kontrollangiographien wurden geplant, wovon bei bisher 5 erfolgten keine Änderung der Größe des Residuums gesehen wurde. Bleibende Folgen aufgrund eines Gefäßverschlusses wurden in 9 Fällen gesehen. Größere intraoperative Rupturen (p < 0,005), Riesenaneurysmata/fusiforme Konfiguration (p < 0,001), Lokalisationen im hinteren Kreislauf (p < 0,05) und im ophthalmischen Segment (p < 0,008) korrelierten signifikant mit negativen clipabhängigen Befunden. Der Einsatz desÂ’Mikrodopplers reduzierte die Rate unerwarteter Gefäßverschlüsse signifikant (3,3 % versus 0,9 %).
Zusammenfassung: In mindestens 10 % aller Fälle sind nach mikrochirugischer Clipapplikation nicht perfekte Ergebnisse zu erwarten, wogegen kein Chirurg und keine Lokalisation immun zu sein scheinen. Unabhängig von der Notwendigkeit zur Qualitätskontrolle nach Aneurysma-Clipping - besonders im Hinblick auf das Coiling -, unterstreichen unsere Ergebnisse daher die Wichtigkeit der routinemäßigen postoperativen Kontrolle, da eine Gruppe von Patienten unmittelbar oder im Verlauf davon profitiert.

Key words

Cerebral aneurysm - surgery - postoperative angiography - residual aneurysm - vessel occlusion

Schlüsselwörter

Zerebrale Aneurysmen - Mikrochirurgie - postoperative Angiographie - Aneurysmarest - Gefäßverschluss

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