Interdisciplinary Neurosurgery (Sep 2021)
Stroke due to middle cerebral artery aneurysm clipping when the intraoperative angiogram was normal
Abstract
Objective: An intraoperative angiogram (IOA) may be used to check the clipping of middle cerebral artery (MCA) aneurysms. This study analyzes the occurrence of a stroke when the IOA was normal as this has not been looked into before. Methods: The records of all patients with a normal IOA after MCA aneurysm clipping were reviewed. Patients who woke up with a stroke were selected for this study and analyzed in detail. Results: Thirty-one patients with 34 aneurysms had a normal IOA. Of those, 7 woke up with a new deficit from perforator or small artery ischemia resulting in a stroke rate of 22.6%. Five out of the 7 strokes were potentially avoidable. Conclusion: An IOA is still an important tool to check the adequacy of clip placement. However, our experience has taught us that the intent to use it should not lessen the amount of time spent dissecting and exposing the aneurysm as completely as possible. The urge to clip the neck and hope that the IOA will be favorable, when the aneurysm is not maximally exposed, should be resisted. Ideally, a full 360 degrees dissection of the aneurysm should be done to identify perforators and small arteries en passage before clipping. If this had been done, it is likely that the stroke rate would have dropped towards 6.5%.
