title: Reversal of intraoperative arterial thrombosis with a fibrinolytic agent when treating large and giant partially thrombosed aneurysms of the middle cerebral artery.
abstract: OBJECTIVE
  Thrombosis of the cerebral arteries is one of the complications of microsurgical operations for partially thrombosed intracranial aneurysms. The object of this study was to assess the frequency of intraoperative arterial thrombosis (IAT) during microsurgical treatment of large and giant partially thrombosed aneurysms of the middle cerebral artery (MCA) and also to assess the efficacy of the treatment of this complication.
  
  
  METHODS
  The authors analyzed a consecutive series of 53 patients who underwent surgery for partially thrombosed aneurysms of the MCA at the Burdenko Neurosurgical Institute between January 2005 and September 2014. Thirty-two patients had large aneurysms (15-25 mm) and 21 had giant aneurysms (> 25 mm). Clipping of aneurysms was performed in 47 patients, trapping was performed in 3, and wrapping was performed in 3.
  
  
  RESULTS
  IAT was diagnosed in 10 patients (18.9%). The authors describe a technique for IAT reversal involving the injection of modified human recombinant prourokinase (mr-proUK). Of the 7 patients who underwent injection of mr-proUK in the thrombosed artery, 5 (71.4%) were discharged without any change in neurological status, 1 (14.3%) experienced moderate deterioration (modified Rankin Scale [mRS] score of 2), and 1 (14.3%) experienced severe deterioration (mRS score of 4). Among the 3 patients who had complications and did not receive an injection of mr-proUK, 2 experienced severe deterioration (mRS score of 3 and 4) and 1 had moderate deterioration (mRS score of 2).
  
  
  CONCLUSIONS
  The primary risk factor of thrombectomy with temporary trapping is thrombosis in the MCA branches. The injection of a fibrinolytic agent into thrombosed MCA branches is an effective method for the treatment of IAT.
authors.affiliation: Vascular (3rd) Department, Burdenko Neurosurgical Institute, Moscow, Russia.
authors.forename: Shalva
authors.initials: S
authors.lastname: Eliava
authors.affiliation: Vascular (3rd) Department, Burdenko Neurosurgical Institute, Moscow, Russia.
authors.forename: Yury
authors.initials: Y
authors.lastname: Pilipenko
authors.affiliation: Vascular (3rd) Department, Burdenko Neurosurgical Institute, Moscow, Russia.
authors.forename: Oleg
authors.initials: O
authors.lastname: Shekhtman
authors.affiliation: Vascular (3rd) Department, Burdenko Neurosurgical Institute, Moscow, Russia.
authors.forename: Anton
authors.initials: A
authors.lastname: Konovalov
mesh_terms: D000328:Adult; D000368:Aged; D002548:Cerebral Revascularization / Q000379:methods; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000523:psychology / Q000601:surgery*; D020767:Intracranial Thrombosis / Q000188:drug therapy* / Q000209:etiology / Q000523:psychology; D007431:Intraoperative Complications / Q000188:drug therapy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000601:surgery*; D009483:Neuropsychological Tests; D019635:Neurosurgical Procedures / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology / Q000523:psychology; D012307:Risk Factors; D017131:Thrombectomy / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome; D014568:Urokinase-Type Plasminogen Activator / Q000627:therapeutic use*
chemical_list: D005343:Fibrinolytic Agents; D014568:Urokinase-Type Plasminogen Activator
keywords: CTA = CT angiography; DSA = digital subtraction angiography; IAT = intraoperative arterial thrombosis; MCA = middle cerebral artery; MCA aneurysm; cerebral artery thrombosis; fibrinolysis; giant aneurysm; large aneurysm; mRS = modified Rankin Scale; mr-proUK = modified human recombinant prourokinase; partially thrombosed aneurysm; prourokinase; thrombectomy; vascular disorders