V.S. Panuntsev, G.A. Asaturyan, V.A. Aliev
(Polenov Research Neurosurgical Institute, Saint Petersburg)
Today the state of the art in the field of aneurysm treatment is characterized by the firmest position of clipping, used in open interventions, and embolization with detachable spirals (coils), performed in endovascular operations. The advantage of any of this method over the other has not been proved. Thus, one can speak of their constructive coexistence. The majority of neurosurgeons continues to give preference to clipping as the most radical operation, tested by the time itself.
An operation outcome is conditioned not only by pathogenetic mechanisms of the disease, but also by possible surgical complications. An intraoperative rupture of aneurysm is of peculiar importance, as surgical technique proper is based on a risk of its appearance to a great extent. Despite this, there is no unanimous opinion about a choice of methods of intraoperative rupture prevention and the most effective means of bleeding control. The last years are characterized by a growing interest in repeated temporary clipping (RTC) of a parent artery. However, there are considerable contradictions, connected with determination of safe conditions of its use. A risk of brain infarction conditions a rather great number of opponents of this method.
An intraoperative rupture of aneurysms was watched in 42 out of 241 cases, operated in the Polenov Research Neurosurgical Institute in 1996-2000. RTC prevented intensive bleeding, ensured more effective hemostasis and absence of massive blood loss. Use of direct methods of hemostasis or forced temporary clipping had a marked negative effect on prognosis. At the same time aneurysm rupture under conditions of RTC did not increase a rate of unfavorable outcomes. A multi-stage statistical analysis of a rate of postoperative ischemic responses, unfavorable outcomes and their dependence on duration of temporary clipping (TC) allowed to determine threshold values for safe use of RTC (15 and 20 min respectively). RTC with reperfusion of no less than 5 min was aimed at reducing duration of continuous occlusion of a parent vessel. We did not watch any local reperfusion trauma, caused by applying temporary clipping. There was no summation of an ischemic effect in RTC, if duration of each of them did not exceed the above threshold values. Repeated clipping of the main trunk of the middle cerebral artery and its efficacy are illustrated by a favorable outcome of a radical open operation, performed in a female patient with a big aneurysm of MCA (video).