title: Does the impact of elective temporary clipping on intraoperative rupture really influence neurological outcome after surgery for ruptured anterior circulation aneurysms?--A prospective multivariate study.
abstract: BACKGROUND
  Elective temporary clipping (ETC) is increasingly used in surgery for aneurysms. This study was to assess whether the impact of ETC on intraoperative aneurysmal rupture (IAR) translates into neurological outcome.
  
  
  METHODS
  Patients who underwent surgery for ruptured anterior circulation aneurysms were prospectively studied for various factors related to ETC, IAR and neurological outcome at 3 months. Univariate and multivariate analyses were performed using SPSS20.
  
  
  RESULTS
  Of the total 273 ruptured aneurysm surgeries studied, IAR was observed in only six out of 132 aneurysms (4.5 %) who had ETC, compared with 78 out of 141 (55.3 %) without ETC (p < 0.001). Aneurysms complicated by IAR had significantly longer clipping time (8.3 min) compared with those without IAR (1.9 min) (p < 0.001). IAR had significant association with unfavorable outcome (38 % vs. 24 %) (p = 0.02). Patients with ETC had significantly shorter clipping time (2.9 min) compared with those without ETC (4.8 min) (p = 0.02). Unfavorable outcome was noted in 30 out of 132 with ETC (23 %), compared with 48 out of 141 without ETC (34 %) (p = 0.04). This beneficial effect was nonsignificantly greater in younger and good clinical grade patients. While episodes of ETC within clipping time of 20 min did not show significant difference in outcome, repeated rescue clipping (45 % unfavorable outcome, p = 0.048) and total clipping time of at least 20 min (75 % unfavorable outcome, p = 0.008) had significant impact on outcome. In multivariate analysis, the use of ETC (p = 0.027) and total temporary clipping less than 20 min (p = 0.049) were noted to result in significantly better outcome, independent of other factors.
  
  
  CONCLUSIONS
  The use of ETC decreased the occurrence of IAR and the total clipping time, thereby leading to significantly better outcome, independent of other factors. While repeated elective clipping within total clipping time of 20 min did not influence outcome, repeated rescue clipping and total clipping time of at least 20 min had significant impact on outcome.
authors.affiliation: Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Sivashanmugam
authors.initials: S
authors.lastname: Dhandapani
authors.forename: Sudhir S
authors.initials: SS
authors.lastname: Pal
authors.forename: Sunil K
authors.initials: SK
authors.lastname: Gupta
authors.forename: Sandeep
authors.initials: S
authors.lastname: Mohindra
authors.forename: Rajesh
authors.initials: R
authors.lastname: Chhabra
authors.forename: Surender K
authors.initials: SK
authors.lastname: Malhotra
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D017542:Aneurysm, Ruptured / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control*; D017558:Elective Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D023261:Glasgow Outcome Scale; D006801:Humans; D015994:Incidence; D002532:Intracranial Aneurysm / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D007431:Intraoperative Complications; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D055815:Young Adult