Symptomatic and silent cerebral infarction following surgical clipping of unruptured intracranial aneurysms: incidence, risk factors, and clinical outcome

Abstract

Cerebral infarction (CI) associated with clipping of unruptured intracranial aneurysms (UIAs) has not been completely studied. The role of individual and operative characteristics is not known, and the risk of silent CI has not been well described. To determine the incidence, risk factors, and clinical outcome of postoperative CI, we retrospectively analyzed 388 consecutive patients undergoing clipping of UIAs between January 2012 and December 2015. We reviewed the pre- and postoperative computed tomography (CT) images of each patient. Postoperative CI was defined as a new parenchymal hypodensity in the vascular territory of treated artery. Patient-specific, aneurysm-specific, and operative variables were analyzed as potential risk factors. Functional outcome at discharge was assessed with the modified Rankin Scale (mRS). Postoperative CI was found in 49 (12.6%) patients, 29 of whom manifested neurological deficits. The incidences of symptomatic stroke and silent CI were 7.5 and 5.2%, respectively. Multivariate analysis showed that larger aneurysm size and history of hypertension were significantly associated with CI. Disability (mRS > 2) rate was 42.9% among patients with CI, which was substantially higher than that among patients without (0.9%). In conclusion, the incidence of CI following clipping of UIAs was not low. Larger aneurysm size and history of hypertension were independent risk factors. Postoperative symptomatic stroke correlated with an extremely high risk of disability. Silent CI was seemingly nondisabling, but the possible cognitive consequence is pending.

Acute ischemic stroke due to unruptured small aneurysm of internal carotid artery

“…Zhang et al's study showed that invasive surgical approach, intraoperative monitoring, effective management of cerebrovascular perfusion, and coagulation can prevent the development of cerebral ischemia and aneurysm rupture. [ 11 ] However, manipulation of the intrasaccular thrombus during coiling can lead to further embolization, [ 12 ] given the risk of intraoperative thromboembolic events, it is possible that the risk of surgery in these patients is higher than in patients with asymptomatic UIA. Further studies are needed before this option can be widely implemented in these patients.…”

Clinical features and outcomes of PComA aneurysms originating from fetal posterior communicating arteries in a single institution

“…In this case, aneurysms grow more easily. In case of blocking or injury of fPCA, infarction develops and patients tend to suffer from poor outcomes because of the lack of compensatory from posterior cerebral circulation [20]. Cerebral infarction is strongly correlated with angiographic vasospasm for ruptured aneurysms.…”

Preventing Rupture: Clipping of Unruptured Intracranial Aneurysms

“…Ischemic complications may also arise from improper clip placement or due to thromboembolism from the aneurysm. The type and severity of neurological consequences depend mostly on the location of the aneurysm [150][151][152][153]. The most frequent type of postoperative events and possibly even underestimated, ischemia leads to poorer outcomes at discharge and often entails a reintervention [153,154].…”

“…The type and severity of neurological consequences depend mostly on the location of the aneurysm [150][151][152][153]. The most frequent type of postoperative events and possibly even underestimated, ischemia leads to poorer outcomes at discharge and often entails a reintervention [153,154]. After clipping of UIAs, transcranial Doppler studies show a decrease in transient reduction in cerebrovascular reactivity on the side of the aneurysm, leading to a proneness toward cerebral ischemia [155].…”

“…Incidence of perforator territory ischemia is higher for aneurysms of the A1 segment, whereas olfactory disturbances are more common for lesions of the ACoA [157]. Silent ischemic lesions are fairly frequent (up to 10% of procedures) and mostly irreversible, though rarely disabling [153,157]. It has been argued that induced hypertension may reduce the effects of delayed cerebral ischemia [158].…”