Jun Thorsteinsdottir, Julian Schwarting, Robert Forbrig, Sebastian Siller, Joerg-Christian Tonn, Thomas Liebig, Christian Schichor
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After iCTA implementation in 10/2016, the majority of patients received additionally iCTA. Baseline characteristics, treatment-related morbidity/outcome, resulting operative conclusions in distinct cohorts with/without iCTA, and management of remnants according to Sindou classification were analyzed.</p><h3>Results</h3><p>270 patients (367 enrolled/97 excluded) were clipped using iCTA in 74 patients. In 12/270 patients (4.5%) clip repositioning was performed due to ICGVA results, but iCTA further detected large remnants intraoperatively in 3/74 patients (4.1%) correctly resulting in re-clipping in two patients and recommendation for endovascular therapy in one patient. The specificity, sensitivity, and accuracy for detection of Sindou grade (SG) III-IV remnants by iCTA were 100%, 75%, and 98.6%, respectively. Overall, pDSA detected SG I-II remnants in 32/270 (11.9%) and SG III-V remnants in 8/270 (3.0%) patients with 3/270 requiring retreatment (<i>n</i> = 1 resurgery, <i>n</i> = 2 endovascular therapy). Frequency of SG I-V and III-V remnants were slightly lower in iCTA than non-iCTA group (10.8 vs. 16.3%, <i>p</i> < 0.173 and 1.4 vs. 3.6%, <i>p</i> < 0.306). All SG I-II and five SG III-V remnants did not reveal growth/rupture after a mean FU of 29 months.</p><h3>Conclusions</h3><p>Aneurysm remnants after clipping are rare and predominantly small (SGI-II)—not harbouring a risk of growth/rupture during short-term FU. 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引用次数: 0
摘要
背景：在专门的神经血管中心，动脉瘤夹断术是一种高效、低并发症的常规手术。术后动脉瘤残余物有生长/破裂的风险。研究目的是分析术后血管造影（pDSA）和随访（FU）中的残留物，并评估术中ct血管造影（iCTA）是否可以术中检测残留物并实现治疗效果。方法所有于2012年11月至2019年12月在我中心行择期动脉瘤夹持术的患者均于2024年1月行FU。所有患者均接受吲哚青素-绿色血管造影（ICGVA）和术后血管造影（pDSA）。2016年10月实施iCTA后，大多数患者接受了额外的iCTA治疗。分析基线特征、治疗相关的发病率/结果、不同队列中有无iCTA的手术结论，以及根据Sindou分类对残余患者的处理。结果74例患者中有270例（367例入组/97例未入组）采用iCTA进行夹持。270例患者中有12例（4.5%）由于ICGVA结果进行了夹重定位，但3/74例患者（4.1%）的iCTA进一步正确检测了术中较大残留物，导致2例患者重新夹夹，1例患者推荐血管内治疗。iCTA检测Sindou分级（SG） III-IV级残留物的特异性、敏感性和准确性分别为100%、75%和98.6%。总体而言，pDSA在32/270（11.9%）患者中检测到SG I-II残留，在8/270（3.0%）患者中检测到SG III-V残留，其中3/270需要再治疗（n = 1例手术，n = 2例血管内治疗）。iCTA组SG I-V和III-V残余的频率略低于非iCTA组(10.8% vs. 16.3%, p <；0.173和1.4 vs. 3.6%, p <；0.306)。所有SG I-II和5个SG III-V残体在平均FU 29个月后未显示生长/破裂。结论在短期FU治疗中，剪断后的动脉瘤残余物很少，且主要是小的（SGI-II），不存在生长/破裂的风险。术中CTA可以发现较大的动脉瘤残余（SG III-IV），并可能提示个别病例调整手术策略。
Detection of remnants in clipped unruptured intracranial aneurysms by intraoperative CT-angiography and postoperative DSA: clinical relevance and follow-up
Background
Aneurysm clipping is routinely performed with high efficacy and low complication rates in specialized neurovascular centers. Postoperative aneurysm remnants bear the risk of growth/rupture. Study aim was to analyze remnants in postoperative angiography (pDSA) and follow-up (FU) and to evaluate whether use of intraoperative CT-angiography (iCTA) can intraoperatively detect remnants and enable therapeutic consequences.
Methods
All patients undergoing elective aneurysm clipping at our center between 11/2012 and 12/2019 were included for FU in 01/2024. All patients received Indocyanin-green-videoangiography (ICGVA) and postoperative angiography (pDSA). After iCTA implementation in 10/2016, the majority of patients received additionally iCTA. Baseline characteristics, treatment-related morbidity/outcome, resulting operative conclusions in distinct cohorts with/without iCTA, and management of remnants according to Sindou classification were analyzed.
Results
270 patients (367 enrolled/97 excluded) were clipped using iCTA in 74 patients. In 12/270 patients (4.5%) clip repositioning was performed due to ICGVA results, but iCTA further detected large remnants intraoperatively in 3/74 patients (4.1%) correctly resulting in re-clipping in two patients and recommendation for endovascular therapy in one patient. The specificity, sensitivity, and accuracy for detection of Sindou grade (SG) III-IV remnants by iCTA were 100%, 75%, and 98.6%, respectively. Overall, pDSA detected SG I-II remnants in 32/270 (11.9%) and SG III-V remnants in 8/270 (3.0%) patients with 3/270 requiring retreatment (n = 1 resurgery, n = 2 endovascular therapy). Frequency of SG I-V and III-V remnants were slightly lower in iCTA than non-iCTA group (10.8 vs. 16.3%, p < 0.173 and 1.4 vs. 3.6%, p < 0.306). All SG I-II and five SG III-V remnants did not reveal growth/rupture after a mean FU of 29 months.
Conclusions
Aneurysm remnants after clipping are rare and predominantly small (SGI-II)—not harbouring a risk of growth/rupture during short-term FU. Intraoperative CTA can detect large aneurysm remnants (SG III-IV) and may prompt adjustment of surgical strategy in individual cases.
期刊介绍：
The journal "Acta Neurochirurgica" publishes only original papers useful both to research and clinical work. Papers should deal with clinical neurosurgery - diagnosis and diagnostic techniques, operative surgery and results, postoperative treatment - or with research work in neuroscience if the underlying questions or the results are of neurosurgical interest. Reports on congresses are given in brief accounts. As official organ of the European Association of Neurosurgical Societies the journal publishes all announcements of the E.A.N.S. and reports on the activities of its member societies. Only contributions written in English will be accepted.
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