In selected cases, e-ICG-A provides the neurosurgeon with information that cannot be obtained by m-ICG-A. e-ICG-A is capable of emerging as a useful adjunct in aneurysm surgery and has the potential to further improve operative results.

C erebral infarction with permanent vasospasminduced delayed ischemic neurological deficits (DIND) after aneurysmal subarachnoid hemorrhage (aSAH) is a feared and unfortunately frequent complication, responsible for poor functional and overall outcome. 2 The pathophysiology of DIND and vasospasminduced delayed cerebral infarction (DCI) after aSAH is multifactorial and still not fully understood. It is well accepted that vasospasm is a major contributor to DIND and DCI, but it is also assumed that processes already initiated shortly after aSAH render some brain areas more vulnerable for vasospasm than others. 20,27,33 In up to 15% of patients, cerebral infarction and a fixed neurological deficit (including death) are irreversible end points of a dynamic process starting with tissue predisposition and asymptomatic vasospasm, followed by symptomatic vasospasm and transient DIND. For the successful prevention of infarction by antivasospastic therapy, timely recognition of abbreviatioNs aSAH = aneurysmal subarachnoid hemorrhage; BFV = blood flow velocity; CBF = cerebral blood flow; CBV = cerebral blood volume; CTA = CT angiography; CTP = CT perfusion; DCI = delayed cerebral infarction; DIND = delayed ischemic neurological deficits; DSA = digital subtraction angiography; MIP = maximum-intensity projection; MTT = mean transit time; NPV = negative predictive value; PPV = positive predictive value; ROI = region of interest; TCD = transcranial Doppler sonography; TTP = time to peak; TTS = time to start. obJective This prospective study investigated the role of whole-brain CT perfusion (CTP) studies in the identification of patients at risk for delayed ischemic neurological deficits (DIND) and of tissue at risk for delayed cerebral infarction (DCI). methods Forty-three patients with aneurysmal subarachnoid hemorrhage (aSAH) were included in this study. A CTP study was routinely performed in the early phase (Day 3). The CTP study was repeated in cases of transcranial Doppler sonography (TCD)-measured blood flow velocity (BFV) increase of > 50 cm/sec within 24 hours and/or on Day 7 in patients who were intubated/sedated. results Early CTP studies revealed perfusion deficits in 14 patients, of whom 10 patients (72%) developed DIND, and 6 of these 10 patients (60%) had DCI. Three of the 14 patients (21%) with early perfusion deficits developed DCI without having had DIND, and the remaining patient (7%) had neither DIND nor DCI. There was a statistically significant correlation between early perfusion deficits and occurrence of DIND and DCI (p < 0.0001). A repeated CTP was performed in 8 patients with a TCD-measured BFV increase > 50 cm/sec within 24 hours, revealing a perfusion deficit in 3 of them (38%). Two of the 3 patients (67%) developed DCI without preceding DIND and 1 patient (33%) had DIND without DCI. In 4 of the 7 patients (57%) who were sedated and/or comatose, additional CTP studies on Day 7 showed perfusion deficits. All 4 patients developed DCI. coNclusioNs Whole-brain CTP on Day 3 after aSAH allows early and rel...

OBJECTIVE Clipping of a ruptured intracranial aneurysm requires some degree of vessel manipulation, which in turn is believed to contribute to vasoconstriction. One of the techniques used during surgery is temporary clipping of the parent vessel. Temporary clipping may either be mandatory in cases of premature rupture (rescue) or represent a precautionary or facilitating surgical step (elective). The aim of this study was to study the association between temporary clipping during aneurysm surgery and the incidence of vasospasm and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) in a large clinical series. METHODS Seven hundred seventy-eight patients who underwent surgical aneurysm treatment after aSAH were retrospectively included in the study. In addition to surgical parameters, the authors recorded transcranial Doppler (TCD) sonography-documented vasospasm (TCD-vasospasm, blood flow acceleration > 120 cm/sec), delayed ischemic neurological deficits (DINDs), and delayed cerebral infarction (DCI). Multivariate binary logistic regression analysis was applied to assess the association between temporary clipping, vasospasm, DIND, and DCI. RESULTS Temporary clipping was performed in 338 (43.4%) of 778 patients during aneurysm surgery. TCD sonographic flow acceleration developed in 370 (47.6%), DINDs in 123 (15.8%), and DCI in 97 (12.5%). Patients with temporary clipping showed no significant increase in the incidence of TCD-vasospasm compared with patients without temporary clipping (49% vs 48%, respectively; p = 0.60). DINDs developed in 12% of patients with temporary clipping and 18% of those without temporary clipping (p = 0.01). DCI occurred in 9% of patients with temporary clipping and 15% of those without temporary clipping (p = 0.02). The need for rescue temporary clipping was a predictor for DCI; 19.5% of patients in the rescue temporary clipping group but only 11.3% in the elective temporary clipping group had infarcts (p = 0.02). Elective temporary clipping was not associated with TCD-vasospasm (p = 0.31), DIND (p = 0.18), or DCI (p = 0.06). CONCLUSIONS Temporary clipping did not contribute to a higher rate of TCD-vasospasm, DIND, or DCI in comparison with rates in patients without temporary clipping. In contrast, there was an association between temporary clipping and a lower incidence of DINDs and DCI. There is no reason to be hesitant in using elective temporary clipping if deemed appropriate.

View Supplementary Video 1 View Supplementary Video 2 View Supplementary Video 3 View Supplementary Video 4

No abstract