title: Safety and efficacy of intraoperative angiography in craniotomies for cerebral aneurysms and arteriovenous malformations: a review of 1093 consecutive cases.
abstract: BACKGROUND
  In an era of indocyanine angiography, the routine use of intraoperative angiography (IOA) in the surgical treatment of aneurysms and vascular malformations is controversial.
  
  
  OBJECTIVE
  To retrospectively assess the safety and efficacy of IOA and to determine predictors of surgical revision.
  
  
  METHODS
  Between 2003 and 2011, IOA was performed during surgical treatment of 976 aneurysms, 101 arteriovenous malformations (AVMs), and 16 arteriovenous fistulas.
  
  
  RESULTS
  In 80 of 976 aneurysms (8.2%), IOA prompted clip repositioning. The reason for readjustment was residual aneurysm in 54.7%, parent vessel occlusion in 42.9%, and both in 2.4% of cases. In multivariate analysis, increasing aneurysm size (P, .001), ruptured aneurysm (P, .001), and increasing number of vessels injected (P, .001) were strong predictors of clip readjustment. There was a strong trend for posterior circulation aneurysm location to predict clip repositioning (P = .06). IOA revealed residual nidus/ fistula requiring further intervention in 9 of 101 AVMs (8.9%) and 3 of 16 arteriovenous fistulas (18.8%). Of 9 AVMs requiring a surgical revision, 2 (22.2%) were Spetzler-Martin grade II, 5 (55.6%) were grade III, and 2 (22.2%) were grade IV. Mean Spetzler-Martin grade was 3.0 in AVMs requiring surgical revision compared with 2.3 in those not requiring revision (P = .05). IOA-related complications were all transient or minor and occurred in 0.99% of patients; none resulted in permanent morbidity.
  
  
  CONCLUSIONS
  IOA remains a valuable tool in the surgical treatment of brain vascular abnormalities, guiding surgical re-exploration in .8% of cases. Easy access to an angiographer and routine use of IOA are important factors contributing to procedural safety and efficacy.
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania 19107, USA. stavropoula.tjoumakaris@jefferson.edu
authors.forename: Nohra
authors.initials: N
authors.lastname: Chalouhi
authors.forename: Thana
authors.initials: T
authors.lastname: Theofanis
authors.forename: Pascal
authors.initials: P
authors.lastname: Jabbour
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Dumont
authors.forename: L
authors.initials: L
authors.lastname: Fernando Gonzalez
authors.forename: Robert M
authors.initials: RM
authors.lastname: Starke
authors.forename: Richard T
authors.initials: RT
authors.lastname: Dalyai
authors.forename: Shannon
authors.initials: S
authors.lastname: Hann
authors.forename: Robert
authors.initials: R
authors.lastname: Rosenwasser
authors.forename: Stavropoula
authors.initials: S
authors.lastname: Tjoumakaris
mesh_terms: D000792:Angiography / Q000009:adverse effects*; D001165:Arteriovenous Malformations / Q000601:surgery*; D003399:Craniotomy / Q000379:methods*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D007431:Intraoperative Complications / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies